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ON
DISEASES OF THE LIVER.
Digitized by the Internet Archive
in 2015
https ://arch i ve .org/detai Is/b21 301 876
ON
DISEASES OF THE LIVER.
BY
GEORGE BUDD, M.D. F.R.S.,
PROFESSOR OF MEDICINE IN KINO’9 COLLEGE, LONDON; AND FELLOW OF CATUS COLLEGE.
CAMBRIDGE.
LONDON:
JOHN CHURCHILL, PRINCES STREET, SOHO
MDCCCXLV.
K/.aT
^61^05 KCOHQ 6^0
LONDON :
PRINTED BY «. J. PALMER, SAVOY-STREET, STRAND,
PREFACE.
The materials of which the present volume is composed accu-
mulated gradually during eight years in which I have been
engaged in hospital practice. For the first three of those years.
I was the visiting Physician to the Seamen’s Hospital, Dread-
nought, where my attention was especially called to diseases of the
liver : which are there very frequent among men who have been
much in India and other hot climates.
The chapter on abscess of the liver formed the substance of
the Gulstonian Lectures, which I had the honour to deliver at
the College of Physicians, in 1842, and which were printed in
the Medical Gazette.
In pursuing my investigations, I have had great help from
my friend and former colleague, Mr. Busk, the accomplished sur-
geon of the Dreadnought, who was not only ever ready to give
me his most valuable aid when we were acting together, hut who
has ever since continued to call my attention to all cases of es-
pecial interest occurring in his practice. All who are versed in the
recent progress of anatomy may form some judgment of the
great value of Mr. Busk’s assistance, in a scientific point of view,
but only those who have the happiness to enjoy his friendship
can appreciate the singular disinterestedness with which it was
given.
IV
PREFACE.
I am also much indebted to my friend, Mr. Bowman, for
microscopic specimens illustrating the structure of the liver, and
for some interesting cases which he has placed at my disposal,
as well as for the readiness with which he has on several occa-
sions aided me by his intimate knowledge of structure.
To Dr. Inman, of Liverpool, and to Dr. James Russel, of Bir-
mingham, my former pupils, I am likewise indebted for some va-
luable cases which they have been kind enough to send me.
This account of the opportunities I have had of studying
the diseases of the liver, and of the great assistance I have
derived from others, will, I fear, lead the reader to expect more
information in the following pages than he will find. To prevent
disappointment, it is right, therefore, that I should add that while I
was in office at the Dreadnought, many opportunities were turned to
little profit, from the ignorance which then prevailed as to the real
structure of the secreting element of the liver ; and that, since, many
have been quite lost from my time and attention having been ab-
sorbed in the business of teaching. It is hoped, however, that with
all its imperfections, of which no one can be more sensible than
myself, the work will contribute to render the diagnosis of dis-
eases of the liver more certain, and their treatment, therefore,
more rational and satisfactory.
Dover Street, June, 1845.
CONTENTS.
Introduction.
Page
Vagueness of our knowledge of Liver diseases — Structure of the liver —
Cause of the variations in its form, size, and colour — Physical
qualities and composition of the bile — Sources and uses of the bile —
Cholagogue medicines . . . . . .1
CHAPTER I.
ON CONGESTION OF THE LIVER.
Congestion of the liver from impediment to the flow of blood through
the lungs or heart — Effects of this — Congestion from other causes —
Portal-venous congestion. . . . . .38
CHAPTER II.
ON THE INFLAMMATORY DISEASES OF THE LIVER.
Section I. General remarks on the classification of inflammatory
diseases of the liver — Suppurative inflammation, and abscess, of the
liver ........ 46
Section II. Gangrenous inflammation — Appearances sometimes mis-
taken for gangrene— Circumstances in which gangrene of the liver
really occurs ..... . . 96
Section III. Adhesive inflammation of the capsule and of the sub-
stance of the liver — Cirrhosis — Other forms of inflammation of the
substance of the liver . . . . , .105
CONTENTS.
viii
Page
Section IV. Inflammation of the veins of the liver— Suppurative
inflammation of the portal vein— Adhesive inflammation of branches
of the portal vein— Inflammation of branches of the hepatic vein . 136
Section V. Inflammation of the gall-bladder and ducts — Catarrhal and
suppurative inflammation— Croupal, or plastic, inflammation — Ulcer-
ative inflammation — Effects of inflammation of the gall-bladder and
ducts — Fatty degeneration of the coats of the gall-bladder . .149
CHAPTER III.
ON DISEASES WHICH RESULT FROM FAULTY NUTRITION OF THE
LTVER, OR FAULTY SECRETION.
Section I. Softening of the liver — Destruction of the hepatic cells —
Suppressed secretion of bile — Fatal jaundice .... 196
Section II. Fatty degeneration of the liver — Partial deposit of fat in
the liver — Waxy liver — Appearances caused by deficiency of fat in
the liver ........ 227
Section III. Scrofulous enlargement of the liver, and other kindred
states ........ 246
Section IV. Excessive and defective secretion of bile — Unhealthy
states of the bile ....... 256
Section V. Gall-stones ...... 272
CHAPTER IV.
ON DISEASES WHICH RESULT FROM SOME GROWTH FOREIGN TO THE
NATURAL STRUCTURE.
Section I. Cancer of the liver — Origin of cancerous tumors of the
liver — Their growth, dissemination, and effects — Encysted, knotty
tubera of the liver ....... 299
Section II. Hydatid tumors of the liver .... 336
CHAPTER V.
On Jaundice.
. 372
Appendix.
1 lie liver-fluke Its effects on sheep and other graminivorous animals —
flukes found in the gall-ducts, in the duodenum, and in branches
of the portal vein, in man ...... 38Q
'■>
FLATS 1 .
EXPLANATION OF THE PLATES.
PLATE I. — Gall-stones.
The drawings for these plates were all taken from preparations in the
museum of King’s College; to which reference is made.
Fig. 1 — Represents small, irregular gall-stones, compost. i of inspissated
and altered bile, cemented by mucus. From a dry preparation, (No. 263,)
which exhibits 279 gall-stones, all of this kind, in the bladder in which they
were found. The bladder is enlarged, but its coats seem not to have been
thickened.
Fig. 2 — Represents a section of a large calculus, composed almost entirely
of cholesterine. It existed alone in the gall-bladder, and weighed three
drachms. (Prep. 264.)
Fig. 3 — Sections of two gall-stones from the same bladder, composed
chiefly of cholesterine, stained by the colouring matters of bile. There were
three other gall-stones, precisely of the same kind, in the bladder. (Prep.
280.)
Fig. 4— Three calculi from the same bladder, two of them sawn through
to show their structure. The bladder contained a great number of calculi
(some have been lost, and thirty-two are still left in the preparation) of the
same kind ; all of them having a crust of pure cholesterine, and all those of
which a section has been made, having a hollow in the centre. (Prep. 284.)
PLATE II. — Gall-stones.
Fig. 1— Sections of two gall-stones of peculiar structure, from the gall-
bladder of a woman who died in King’s College Hospital, of cancer of the
b
X
EXPLANATION OF THE PLATES
li\ er, at the age of 51. The bladder was somewhat contracted at its middle,
so as to form two pouches in which the stones were contained ; and its coats
were much thickened. (Prep 279.)
Fig. 2 — Gall-bladder and cystic duct containing calculi- The calculi
have all a crust of pure cholesterine. (Prep. 269.)
Fig. 3 — Gall-bladder filled with calculi, which have all a crust of pure
cholesterine. From a man, 64 years of age, who died in King’s College
Hospital, of softening of the brain. No disease of the liver was suspected.
(Prep. 261.)
D? vreotmacott. del
H Adlard. ir
ON
DISEASES OE THE LIVER.
INTRODUCTION.
Vagueness of our knowledge of Liver Diseases. — Structure of
the Liver — Cause of the variations in its form, size, and
colour. — Physical qualities and composition of the bile. —
Source and uses of the bile. — Cholagogue medicines.
In writing a book on Diseases of the Liver, I shall hardly he
accused of haring undertaken a needless task. There are no
other diseases of such frequent occurrence, which it is so diffi-
cult to discriminate, and for the treatment of which the medical
practitioner has so few trustworthy guides. There is, again, no
class of diseases at all equal to this in importance, on which so few
treatises have lately been written.
Diseases of the liver occupied a much larger space in the.'
medical literature of former times than they do in that of our own.
Before the functions of the liver had been much investigated, and
before its intimate structure was known, physicians saw, in the large
size of this organ, in its existence in animals differing widely in
organisation and habits, and in the obvious relation of its secretion
to the process of digestion, sufficient evidence of its great impor-
tance in the animal economy, and of the serious consequences that
must result from derangement of its functions.
This evidence has been enhanced and extended by the more
explicit results of modern inquiry. Guided by the comparatively
recent discovery, that a gland may be regarded as consisting
essentially of a net-work of capillaries investing a secretory
duct, anatomists have found a liver, in the form of ccecal tubes
B
2
INTRODUCTION.
opening into tlie intestinal canal, in almost the lowest animals, and
have thus furnished the surest testimony that can be given to the
importance of an organ ; namely, its all hut universal presence in
the animal kingdom.
Notwithstanding this, while the press has been teeming with
works on the diseases of the Nervous System, of the Chest,
of the Kidney, of the Skin, comparatively few have appeared of
late years, on diseases of the Liver. This, assuredly, is not owing
to any falling off in our sense of their importance, hut to the
vague and unsatisfactory state of our knowledge respecting them.
The scientific precision lately given to our knowledge of many
other diseases by the employment of new methods of investiga-
tion, has created a demand for more exact information, in every
branch of medical inquiry, than pathologists have been able to
communicate on diseases of the liver.
The unsatisfactory state of our knowledge of these diseases
will scarcely be wondered at, if we reflect that many causes have
conspired to render the study of them peculiarly difficult.
One of the most influential, perhaps, is, that the colour and tex-
ture of the liver are such as to make it difficult, 'with the imperfect
means of research hitherto employed, to detect and define, in the
dead body, the various effects of disease, unless where this has
gone on to disorganisation, or complete change of structure.
In an organ whose texture is spongy, as the lung, disease pro-
duces such striking changes, that we can at once distinguish their
different forms, and thus leam to connect them with the symp-
toms observed during life ; but in organs naturally solid, and
also nearly of the colour of blood, as the liver and the kidney,
these chtinges, and especially the traces of the various kinds of
congestion and inflammation, are far less obvious, and to detect
and discriminate them, requires a knowledge of intimate structure
which has only lately been obtained, and, even with that knowledge,
a very close and minute inspection.
In the case of the kidney, the impediment which these condi-
tions offer to the morbid anatomist is well illustrated by the
fact, that a disease so common and so fatal as granular dege-
neration of this organ, and signalized during life by such marked
symptoms as general dropsy and albuminous urine, has been left
to immortalize, by its discovery, the name of a living physician ;
and that even now, notwithstanding the interest it has excited for
INTRODUCTION.
3
seventeen years, and tlie attention given to it by the best anato-
mists of this and other countries, the real nature of the morbid
change in which it essentially consists, is a matter of doubt.
Another circumstance unfavourable to the study of diseases of
the liver is, that we can obtain but little direct evidence of its
physical condition during life.
When the lungs are the seat of disease, we may discover by the
sense of hearing, whether any portion of them near the surface contain
the natural quantity of air, or whether this, in whole or in part, be
displaced by some denser matter ; whether the surface of the pleura
be roughened by fibrine, or its sac distended by fluid ; whether the
bronchial tubes be free, or more or less choked by secretions.
If the heart be the organ affected, we may not only trace its
outline and estimate the strength of its ventricles, but, by the
same sense, penetrate its interior, and ascertain the condition of
its valves. The whole physical structure of the organ is, as it
were, laid open to us.
We have it in our power indeed to explore the liver by touch and
by percussion, but we cannot, by these means, penetrate its surface,
and discover changes in its consistence and texture. They only
enable us, in some cases, to trace its outline, to discover any striking
inequalities of its surface, and to form a tolerable estimate of its bulk.
This, indeed, is valuable information, and more than we can learn
of the kidneys by similar means. But in investigating the
diseases of the latter, we have the more than equivalent advantage,
that, day by day, we can measure the quantity, and ascertain the
composition, of the urine secreted : that is, we can tell precisely
the manner in which their functions are performed.
The secretions of the liver, on the contrary, cannot be collected
and analysed during the life of the patient ; indeed, until lately,
they could scarcely be analysed at all, as the most celebrated
chemists were not even agreed as to what are the normal consti-
tuents of bile.
Thus, to detect and distinguish the diseases of the liver,
practitioners had little more than the signs of functional dis-
turbance ; — signs, in all cases of doubtful import, and here, if we
except that of jaundice, more than commonly obscure and
equivocal. We cannot, then, feel surprised that our knowledge of
these diseases should be more imperfect, our diagnosis of them
less sure, and our treatment, consequently, more tentative and cm-
b 2
4
INTRODUCTION.
piricftl, than of the diseases of any other organ of equal impor-
tance.
Very recently, two of the impediments to the study of diseases
of the liver have been in some degree removed. By the re-
searches of chemists we have obtained more precise knowledge
of the composition and uses of bile ; and by the labours of
Kiernan and Bowman in this country, and of Muller and Henle
in Germany, we have been taught the intimate structure of the
organ ; so that now, by the naked eye or the microscope, we can
distinguish the various changes of its texture produced by disease.
It is impossible to explain or understand the morbid appear-
ances of the liver, without referring to its intimate structure, and
as some points relating to this have been only lately made out, I
shall commence with a short account of it.
Perhaps the best way to get an idea of the structure of the
liver, is to examine under the microscope,
1st. A thin slice of liver, in which the portal and hepatic veins
are thoroughly injected.
2nd. A small particle taken from the lobular substance of a
fresh liver in which the blood-vessels are empty, as in an animal
killed by bleeding.
From the first specimen we may learn the distribution of the
minute portal and hepatic veins, and the intermediate capillaries.
The annexed woodcut (fig. i.) has been made from a por-
tion of the liver of a frog, which I selected from the numerous
specimens of injected liver made by Mr. Bowman. It represents
on a magnified scale, a small branch of the hepatic vein, two or
three small branches of the portal vein, and the intermediate ca-
pillaries. It appears that the capillaries have nearly the same
relation to the branches of the portal vein, as they have to
those of the hepatic vein. It is difficult from this specimen to tell
which branch is portal, which hepatic ; the smaller branches of both
being, as it were, hairy with capillaries springing directly from
them on every side and forming a close and continuous network.
By conceiving similar views of the branches of the two veins and
their intermediate capillaries, obtained by slicing the liver in various
directions, we shall perceive that the entire organ, abstracting
the canals in which the trunk and branches of those veins run,
is ocoupied by a close network of capillary blood-vessels, con-
DISTRIBUTION OF VESSELS.
Fig. 1.
a a, twigs of the portal vein ; d, twig of the hepatic vein ; b, intermediate
capillaries.
tinuous in every direction throughout its substance. The capil-
lary vessels of this network immediately minister to the secretion
of hile. The vessels of larger size serve merely to convey the blood
to them, or carry it from them.
These capillaries are of comparatively large size, being always one-
third wider than the diameter of the blood-globule, and sometimes
nearly twice as wide, and their coats, which have no areolar tissue
about them, appear very thin and delicate.*
But although the capillaries form a continuous network through-
out the substance of the liver, no part of the portal blood tra-
verses the entire network. The whole mass of capillaries is
divided by the minute branches and twigs of the portal vein into
small, tolerably defined masses ; and is likewise partitioned in a
similar way, by the minute branches and twigs of the hepatic
* See an admirable article on Mucous Membrane, by Mr. Bowman, in
Todd’s Cyclopaedia of Anatomy and Physiology, in which several points in
the minute structure of the liver noticed in this chapter, were first published.
6
INTRODUCTION.
vein, which are intermediate to, or, as it were, dovetailed with, the
branches and twigs of the portal vein. In effect of this, the blood
conveyed through any branch of the portal vein to a small
mass of capillaries, having performed its part in secretion and
been drained of the principles of bile, passes out of the liver
through an intermediate or adjacent branch of the hepatic vein,
so that the entire mass of capillaries is duly supplied with fresh
portal, or biliary, blood.
In tracing even large branches of the portal and hepatic veins,
we see that they generally run transversely, or that the directions
of the two orders of vessels cross each other.
In consequence of this arrangement of the minute vessels, if we
cut into a liver in which, as is usual after death, the branches and
twigs of the hepatic vein and the capillaries immediately terminat-
ing in them, are full of blood, while the branches and twigs of
the portal vein and the capillaries immediately springing from
them are empty, the cut surface will be mapped out into
small, tolerably equal, and somewhat pentangular, spaces, having
the outline, formed by the portal twigs, pale, and the centre, into
which a twig of the hepatic vein enters, red. The small masses of
which these pentagonal spaces are sections, have been termed lobules
of the liver. They have been described by Malpighi, Kiernan,
Miiller, and others, as isolated from each other, and each invested by
a layer of areolar, or, as it used to be named, cellular, tissue. The
injected preparations of Mr. Bowman show, I think, clearly, that
this opinion is erroneous — that the lobules are not distinct, isolated
bodies, but merely small masses tolerably defined by the ultimate
twigs of the portal vein and the injected or uninjected capillaries im-
mediately contiguous to them. The ultimate twigs of the vein are,
as it were, hairy with capillaries, springing directly from them on
every side and forming a close and continuous network. The lo-
bules appear distinct isolated bodies only when seen by too low a
power clearly to distinguish the capillaries.
The real nature of the lobules and the manner in which they
are formed, will perhaps be better understood by reference to the
annexed woodcut, (fig. 2,) for which I am indebted to the kind-
ness of Mr. Bowman. It represents on a magnified scale six
lobules of the liver, and was made from a drawing under the
microscope, of a section of the liver of a cat, partially injected
through the portal vein, and also through the hepatic vein ; a a. a
LOBULES.
7
Fig. 2.
represent minute twigs of tlie portal vein injected; b b b, capil-
laries, likewise injected, immediately springing from them, and
serving with them to mark the outline of the lobules ; d d d, ca-
pillaries in the centre of the lobules, injected through the hepatic
vein ; e e, places at which the size injected into the portal vein has
met that injected into the hepatic vein, so that all the interme-
diate capillaries are coloured and conspicuous ; l l, centres of
lobules into which the injection has not passed through the he-
patic vein.
Since the capillary network of the liver has nearly the same re-
lation to the minute branches and twigs of the hepatic vein, as to
the minute branches and twigs of the portal vein, we might have
anticipated that a similar appearance of lobules might be formed ;
the circumference of each being marked by twigs of the hepatic
vein and the capillaries immediately surrounding them, and the
centre by a twig of the portal vein. This appearance is seen in
what has been called, by Mr. Kicrnan, the second stage of hepatic
venous congestion.
8
INTRODUCTION.
When the portal vessels are empty, and only the hepatic twigs
and the capillaries immediately contiguous to them are filled with
blood, there is an appearance of lobules, having a pale outline
formed by the terminal twigs of the portal vein. The centres of
the lobules appear as small, isolated, red spots.
If the injection extend from the twigs of the hepatic vein into
the capillaries, but be not continued quite far enough to reach the
twigs of the portal vein, all the capillaries of the lobular substance
will be injected, except those immediately springing from the
portal twigs, and a section of the liver will present small, isolated,
pale spots, where the uninjected twigs of the vena porta are
divided. These spots being surrounded by a red band continuous
throughout the liver, gives rise to an appearance of lobules just
like those formed by injecting the twigs and capillaries of the vena
porta, so as not to fill those of the hepatic vein.
It has been stated that the capillaries have the same relation to
the small branches and twigs of the hepatic vein, as to those of the
portal vein. This statement, however, requires some qualification.
The branches of the portal vein are each accompanied to their
Longitudinal section of a small portal vein and canal. P, the portal vein ;
A D, the accompanying artery and duct ; a a, portions of the canal from
which the vein has been removed; b, orifices of ultimate twigs of the vein,
springing immediately from it.
p
Fig. 3
\ D
PORTAL AND HEPATIC VEINS.
9
smallest twigs by a branch of tbe hepatic artery, and one of the
hepatic duct. These vessels, which are very much smaller than
the corresponding portal vein, run up (as seen in fig. 3#) on one
side of it, and of course on that side the capillaries cannot spring
so immediately from the venous trunk ; in other words, the lo-
bules are not in such immediate contact with the vein. The capil-
laries terminate in twigs which go to the vein through the space
which the presence of the artery and duct necessarily interposes
between the lobules and the vein.
The artery and duct are also liable to changes in volume, which
is permitted by some areolar tissue being placed in the portal
canals, surrounding the artery and duct, and continued in a thin
Fig. 4.
H, longitudinal section of an hepatic vein, a, a, portions of the canal, from
which the vein has been removed ; b, b, orifices of ultimate twigs of the vein,
formed hy the capillaries of single lobules.
* This figure and the two following ones, are copied from the admirable
paper on the Liver in the Transactions of the Royal Society for 1833, by Mr.
Kiernan, to whom we are in great part indebted for the exact knowledge we
now have of the distribution of blood-vessels in the liver, and of many other
points of its structure.
10
INTRODUCTION.
layer round the branches of the portal vein itself. This layer
separates by a small space the lobules from the branches of the
vein, and makes the coats of the latter appear thicker than those
of the hepatic veins, and their outline more distinct ; and also
allows them to collapse when empty.
The hepatic veins are not accompanied by any other vessels,
and are not surrounded by areolar tissue, and, in consequence,
are everywhere in immediate contact with lobules. In the small
branches the coats are thin and transparent, and capillaries, or the
ultimate twigs formed from the capillaries, enter them directly on
every side. In the larger branches, the coats are thicker and
opaque, and the ultimate twigs unite to form larger twigs before
they enter the vein. This is shown in figure 4, copied on a
smaller scale from one by Mr. Kiernan.
To complete our view of the blood-vessels of the liver, we must
consider the hepatic artery.
We have already seen that a branch of the artery accompanies
each branch of the portal vein and hepatic duct. It has been
shown by Mr. Kiernan, that the hepatic artery is distributed to,
and nourishes, the coats of the gall-bladder and ducts, the liga-
ments of the liver, its capsule, and the coats of the portal and
hepatic veins ; and that the blood conveyed to all these parts by
the artery passes into veins which terminate in branches of the
portal vein, and ministers to the secretion of bile, like blood re-
turned from the other abdominal viscera.* These veins, which
originate in the liver, and feed the porta with the blood brought
by the hepatic artery, constitute what Mr. Kiernan has called the
hepatic origin of the portal vein. No arteries enter the lobules of
the liver.
The blood brought by the hepatic artery is distributed chiefly
to the ducts. Mr. Kiernan remarked, that “ When the arteries
are well-injected, the larger ducts from the extreme vascularity
of their coats, may be mistaken for injected arteries, whilst in
the coats of the vein, no vessels will be detected without the
aid of the magnifying glass.” The blood of the hepatic artery,
not only nourishes the coats of the excretory ‘portion of the
ducts, but furnishes the materials of their proper secretion.
* It appeal's from some injections by Mr. Bowman, that some of the arte-
» ial capillaries of the capsule return their blood, not into a branch of the portal
vein, but immediately into the adjacent capillary plexus of the portal vein.
NUCLEATED CELLS.
11
the arteries in the
Fig.
The ducts, as we have seen, accompany
portal canals. Each portal vein, however
small, has an artery and a duct running
along it. The coats of the duct are
supplied with blood entirely through
the hepatic artery, which forms a close
network over the mucous membrane.
In the large ducts, and in the gall-
bladder, the mucous membrane is thrown
into folds. The inner surface of the
ducts presents besides a great number
of follicles, which in the large ducts are
distributed irregularly, but in the small
ones are ranged in two lines on oppo-
site sides of the canal.
Having obtained a conception of the distribution of vessels in
the liver, we may next consider the other elements of its structure.
This is, perhaps, best done by examining under the microscope
a small particle taken from the lobular substance of a fresh
liver, empty of blood and uninjected.
In such a specimen, all we see under the microscope is a mass
Section of a small gall-duct,
showing the follicles.
Fig. 0.
of nucleated cells, with, here and there,
a fibre from one of the torn vessels.
The cells are flattened, irregular in
form, but somewhat spheroidal, and have
each a nucleus, which again contains
a central pellucid spot, the nucleolus.
Some cells have two nuclei.
The cells are of various sizes. The
largest are usually about the one-thou-
sandth of an inch in diameter. Others
are very much smaller, as if not yet fully
developed. In some livers the cells,
generally, are smaller than in others.
The cells contain oil-globules and
amorphous granular matter. Their co-
lour and transparency depend on the
colour and quantity of the matter they contain, which vary very
much in different cases. They arc usually of a light brown and
Nucleated cells of the li-
ver ; a, the nucleus ; b, the
nucleolus; c, fat-globules;
d, cells of small size, de-
tached.
12
INTRODUCTION.
almost transparent, but in some subjects we find them yellowish
and opaque.
If, while looking at this mass of nucleated cells, we imagine
the delicate and now invisible capillaries to be filled with blood,
or coloured size, and thus rendered conspicuous, we shall per-
ceive, that the whole liver, excluding the canals in which the
portal and hepatic veins run, is a solid plexus of capillary blood-
vessels, the meshes of which are filled with nucleated cells.
The mucous membrane of the gall-bladder and ducts, like the
excreting ducts of other glands, in fact, like all mucous mem-
branes and the skin itself, is composed, as Mr. Bowman has
shown, of an extremely thin, transparent membrane, without
pores or visible structure, whose external or secreting surface, is
coated with nucleated cells. These oells, by their apposition and
union, form a kind of pavement on the transparent membrane,
which, serving as their basis of support, has for this reason been
named by Mr. Bowman the base7nent-mQmbmn.e. The blood-
vessels, lymphatics, and nerves ramify on the opposite, deep, or
inner surface of the basement-membrane.*
But although mucous membranes are alike in structure, they
being all composed of a basement-membrane, paved, if we may so
express it, with nucleated cells, yet the cells differ much in form
and appearance, in different situations.
In the tubuli of the human kidney, the cells, like those of the
substance of the liver, are spheroidal. In the gall-bladder and
Fig. 7.
Nucleated cells of the gall-bladder, as seen under a high power; a, pave-
ment formed by the union and apposition of the cells ; b, side-view of four
cells ; c, the basement-membrane ; d, a detached cell.
* For ample details on this point I may refer the reader to the article
Mucous Membrane, in Todd’s Cyclopaedia.
OFFICE OF THE CELLS.
13
ducts, as on the villi of the small intestine, the cells have the
form of prisms.
If the gall-bladder he bruised a little, a portion of the bile
taken from it exhibits under the microscope hundreds of these
prismatic cells. The opaque mucus we sometimes find in an in-
flamed gall- duct is almost made up of similar cells, which in the
small ducts are very long and tapering.
There can be no doubt that the cells lining the gall ducts are
continuous with the nucleated cells in the meshes of the capillary
network of the fiver, but the basement-membrane has not been
traced beyond the ducts ; and, at present, we do not know how the
ducts terminate. They cannot be traced into the lobules of the
fiver. Mr. Kiernan has indeed given a figure of what he calls the
lobular biliary plexus, in which the bile-duct is continued into the
lobule, forming there a plexus which interlaces with the plexus of
capillary vessels. But he means the figure to he a diagram only.
He confesses that no such view of the ducts can he obtained.
All that has been actually observed of the arrangement of the
cells within the lobule, is what has been observed by Mr. Bowman,
that the cells have in some measure a radiating arrangement from
the central axis towards the circumference, or towards certain
parts of the circumference ; so that, when a lobule is torn up for
examination under the microscope the cells are apt to form a
linear series.*
The researches of Purkinje, Henle, Bowman, and Goodsir, leave
no doubt that the nucleated cells are the immediate agents of
secretion.
It is not in the fiver only that the cells perform this office, for
it seems established as a general law, and it is certainly one of the
highest and most interesting which the study of minute structure
has yet disclosed — that all true secretion, whether in animals or
in plants, is effected by the agency of cells ; that, “ however
* Professor Weber and Dr. Krukenberg, in two papers recently published
in Muller’s “Archiv.,” maintain the opinion advanced by Mr. Kiernan, that
the bile-duct is continued into the lobule, forming there a plexus interwoven
with the plexus of capillary blood-vessels. They state that this lobular
biliary plexus has been seen by them in the injected liver of the frog. Both
these anatomists assent to the opinion advanced by Mr. Bowman, and
maintained in this chapter, that the lobules of the liver are not isolated
from each other, as was formerly supposed, by an investment of areolar
tissue.
14
INTRODUCTION.
complex the structure of tlio secreting organ, these nucleated
cells are its really operative part.” In each secreting organ, the
secreting cells have a peculiar power to form, or to withdraw from
the blood, the secretion proper to the part.
In such of the glands of animals as have excreting ducts, the
nucleated cells withdraw from the blood the peculiar principles of
the secretions, which they elaborate more or less, and then, in one
way or another, whether by bursting, or dissolving, or by some un-
known mode, discharge them through the excreting ducts.
The evidence of this is, perhaps, as clear in the liver as in
any of the glands.
On examining the nucleated cells of the liver under the micro-
scope, we see that most of them inclose small spheroidal globules,
which are recognised by their dark outline, or high refractive
power, to he globules of oil or fat.
In ordinary livers these oil or fat globules are small, and few in
number ; hut in the fatty condition of the liver, so often found in
persons dead of phthisis, and in that induced by keeping
animals exclusively on fatty substances, they are so large and
numerous as to distend the cells to double their natural size, and
consequently to cause a great increase in the volume of the liver.*
Fig. 8.
Nucleated cells, from a liver in a state of fatty degeneration : a, nucleus ;
b, nucleolus ; c, c, c, fatty globules. (Bowman.)
From the high refracting power of oil globules we have, then,
ocular proof that fatty matters taken into the system in too great
quantity pass from the blood into the nucleated cells of the liver.
There can be no doubt that they pass, either bodily or more or
less changed, from these cells into the excreting ducts.
Most of the peculiar principles of bile are allied to fat, in con-
taining a large proportion of hydrogen and carbon, and are, no
doubt, eliminated in this way ; namely, by passing from the blood
into the nucleated cells, and on the bursting or breaking down of
* See Lancet, January, 1842.
LYMPHATIC VESSELS AND NERVES.
15
these, becoming discharged through the excreting ducts, so as to
form the matter of secretion.
Direct ocular proof may also be often obtained that the co-
louring matters of the bile are contained in the nucleated cells-
Henle, in his recent edition of Soemmering, describes the nu-
cleated cells of the liver as appearing yellowish or yellowish-brown
in direct light, and as probably containing the colouring matter of
bile ; but Mr. Gulliver was, I believe, the first who distinctly ob-
served the colouring matter of bile in the nucleated cells.
In the livers of two persons who died jaundiced, he found an
unusual quantity of this biliary colouring matter, which was col-
lected chiefly round the nuclei, but was also scattered throughout
the cells. In some cells it was in such quantity as to render them
nearly opaque.*
I have repeatedly observed the same thing. Indeed the colour-
ing matter of the bile can always be seen in the. cells taken from
the roundish yellow masses in Cirrhosis, or from any portion of a
liver which has a well-marked yellow or green tint. The colour-
ing matter in the cells presents exactly the same appearance
under the microscope as the colouring matter in the bile.
Mr. Goodsir has given a long list of animals, in which he ob-
served in the cells of the liver, or of csecal tubes supplying the
place of a liver, matter of an amber tint, or of various shades of
brown, according to the animal examined, but in each having
nearly the colour of the bile.
We can hardly have more convincing proof that, in the liver,
these cells are the real agents of secretion.
Mr. Goodsir supposes that the secretion is effected by the outer
cell membrane, and that the nucleus is the reproductive organ of
the cell.
I have already alluded to the areolar tissue of the liver. This,
which serves to protect the essential elements of the organ is, in
man, spread in a dense layer over its surface, forming the proper
capsule of the liver, and is continued into its interior in the portal
canals. It is in greatest quantity on that side of the portal vein
on which the duct and artery run, but a thin layer of it com-
* This statement, and the quotation above, are taken from an admirable
essay “ On the Origin and Functions of Cells,” by Dr. W. Carpenter, pub-
lished in the twenty-eighth number of the British and Foreign Medical Review.
1G
INTRODUCTION.
pletely invests the branches — at least all the considerable branches
— of the vein. It cannot he traced further than the ultimate twigs
of the artery and duct, and seems not to enter the capillary network.
To make up the rest of the organ there remain the lymphatic
vessels and the nerves.
The superficial lymphatics ramify in the proper capsule of the
liver. Mr. Kiernan states that after injecting these vessels in the
human liver, the peritoneal coat may he removed without injuring
them ; or the peritoneal coat may he first removed, and the ab-
sorbents afterwards injected.
They are spread over the whole surface of the liver. Those on the
convex surface unite to form branches, some of which run to the
lymphatic glands around the inferior cava; others pass through
the diaphragm to the posterior or anterior mediastinal glands.
The lymphatics on the concave surface of the liver also take
different courses : those on the right lobe run to the lumbar
glands ; those on the left lobe, to the glands situated along the
lesser curve of the stomach.*
The deep-seated lymphatics of the liver ramify in the portal
canals, beyond which they have not been traced. No vessels of
this kind accompany the hepatic veins. They seem to be very
closely connected with the ducts. If the ducts he injected, bile
and the matter of injection are frequently forced into the lympha-
tics. About the gall-bladder, too, the lymphatic vessels are very
numerous and large.
The lymphatics of the gall-bladder pass to the glands in the
right border of the lesser omentum ; those from the portal canals
to the glands situated in the course of the hepatic artery and along
the lesser curve of the stomach.
The nerves (derived from the hepatic plexus) likewise accom-
pany the arteries and ducts in the portal canals, but little is known
of their distribution.
A knowledge of the structure of the liver enables us to explain
the variations so often met with in the size, and form, and texture,
of the liver, as well as the various shades of colour of which it is
susceptible, and which have so taxed the descriptive powers of
morbid anatomists.
The mass ol the liver is, as we have seen, made up of a plexus
* Wilson. Anatomist’s Vade-Mecum, p. 361.
SIZE AND COLOUR OF THE LIVER.
17
of capillary bloocl-vessels, the meshes of which are filled with
nucleated cells containing the peculiar principles of the biliary
secretion.
The size of the liver will, of course, vary in some measure with
the degree of congestion or quantity of blood in the capillaries ;
but it depends much more on the number and volume of the cells.
If, as in the fatty degeneration of the liver, the cells are distended
with oil-globules, the lobules of the liver are large and unusually
distinct, and the liver much increased in size and thickened. If,
on the contrary, the cells be fews and small, the lobules will be
small, and the lobular structure distinguished with difficulty, un-
less different portions of the lobules be differently coloured by
partial injection of the capillaries ; and the whole liver will be
small and thin, or, as it were, flattened.
The size of the fiver may also be increased by the interstitial
deposit of the various products of inflammation ; by dilatation of
the ducts ; and by the growth of cancerous or other tumors.
But independently of conditions affecting its structure, the fiver
may be much altered in form by external pressure. By tight
lacing, for instance, the length of the fiver from above down-
wards is often mucfi increased, and its lower portion flattened.
The portion of fiver above an aneurysmal tumor may also be
very much flattened, without any marked change of structure.
Flatulent distension of the large intestine even, if long continued,
may much alter its outward form. *
The firmness of the fiver varies, not only witfi the firmness of
the capillary vessels, the quantity of blood they contain, and the
proportion of fibrine in the blood, but also in some measure with
the state of the cells. When the cells are distended with oil, the
liver is unusually soft, unless it contain newly-formed fibrous
tissue, the result of interstitial deposit of coagulable lymph.
When the fiver is unnaturally firm and dense, it is generally from
the presence of new fibrous tissue formed in this way.
* A short time ago, I met with a remarkable instance of this in a man who
died after having been paraphlegic many months, in consequence of disease
of the dorsal vertebrae. The large intestine, which had been greatly dis-
tended with gas from the commencement of the paraphlegia, was found of
very large size, and lodged in a deep groove which it had formed in the liver.
A cast of the liver was taken, which is now in the museum of King’s
College.
C
18
INTRODUCTION.
The colour of the liver depends on the quantity of blood in the
capillary vessels, and on the quantity of oil and of biliary colour-
ing matter in the cells.
The tint due to the blood varies from pale to a deep venous red,
according to the empty or congested state of the capillaries ; that
due to the cells from a light fawn to a deep olive, according
to the quantity of oil globules and biliary colouring matter they
contain. The actual tint of the liver is the combined effect of the
tints due to the vessels and the cells singly.
In persons who have died from hemorrhage from the stomach or
intestines, or from chronic dysentery, or in great general anemia, as
in the advanced stage of granular kidney, the liver is always found
very anemic, and its colour depends almost entirely on the state of
the cells. In portions of liver of an orange or green tint, the colour-
ing matter on which this tint depends, may always he seen in the cells.
In effect of partial injection of the capillaries, the liver, after
death, generally presents two colours— a yellowish colour and a
red — the former belonging to the uninjected portion, the latter to
the injected portion, of each lobule. This gave rise to the notion
which, until the researches of Mr. Iviernan, was held by all anato-
mists, that there are two substances in the liver, a yellow sub-
stance and a red, which were supposed to constitute the medullary
and cortical part of each lobule. It was Mr. Kiernan who first
showed conclusively, that the mottled appearance so frequently
observed in the fiver, is owing to part only of its blood-vessels
being full of blood ; and that in the great majority of cases in
which it presents this appearance, the hepatic veins and the capil-
laries that terminate in them are the full vessels; the portal veius
and the capillaries that spring from them, the empty ones.
Having examined the structure of the fiver, we may next con-
sider the composition and uses of the bile.
We have seen that the nucleated cells in the lobules of the fiver
withdraw from the blood the principles of then’ secretion, which
they probably elaborate in some degree, and then discharge into
the ducts. In its passage through the ducts the matter secreted
by the lobules becomes mixed with that secreted by the ducts
themselves, which, if we may judge from the large quantity of
blood the ducts derive from the hepatic artery and the numerous
involutions of their mucous membrane, must he considerable in
PHYSICAL PROPERTIES OF THE BILE.
19
quantity. Secretion is always going on, both in the lobules and
in the ducts, and the compound fluid derived from these two
sources probably passes continuously along the ducts as far as the
junction of the hepatic duct with the cystic.
When the stomach and duodenum are empty, part only of the
bile flows along the common duct into the duodenum ; the re-
mainder passes down the cystic duct into the gall-bladder.
During digestion, on the contrary, the gall-bladder contracts,
and pai’t of the bile accumulated in it, together with all that
brought by the hepatic duct, is poured into the duodenum. *
In the gall-bladder, the bile loses, by absorption, some of its
more watery parts, and is further modified by the addition of
the proper secretion of this cavity. After death, if it be not soon
removed from the body, it becomes still further altered. Its more
liquid part continues to pass out, giving a greenish stain to the
tissues in contact with the gall-bladder, while the serum of the
blood and the gaseous and liquid contents of the intestines pass
in the opposite direction through the coats of the vessels and in-
testines and gall-bladder, and become mixed with the bile.
The bile in the gall-bladder is of a greenish-yellow colour,
which varies much in depth, according to the composition of the
bile itself and its degree of concentration. If much diluted or
thinly spread over a white surface, its colour is yellowish, but if
concentrated and seen in mass, it is of a dark green or olive,
sometimes approaching to black. It has been described as having
a peculiar sickly odour, somewhat like that of melted fat, but the
odour of healthy human bile, when fresh and not mixed with in-
testinal gases, is scarcely perceptible. Bile has a nauseous bitter
taste, which leaves behind it a smack of sweetness. It is more
or less viscid, has an unctuous feel, and in many of its physical
properties has great analogy with soaps. It combines readily
with water in any proportion, mixes freely with oil or fat, and
foams, when stirred, like soapy water; and is, indeed, in com-
mon use in the same way for cleaning articles of dress, and espe-
cially for taking out grease. It will be seen, hereafter, that these
properties are probably closely related to one of the physiological
uses of the bile. When evaporated, it leaves inspissated mucus,
* Bouisson — De la bile et de ses varietes physiologiques, et de ses altera-
tions morbides. Paris. 1843.
20
INTRODUCTION.
and a variable proportion of a yellowish-green matter, which is
very bitter, and which dissolves almost completely in water and
alcohol. Bile is heavier than water, but its density varies much
according to its composition and degree of concentration. That
from the gall-bladder of the ox has usually a specific gravity
between T02G and T030. Cystic bile has been generally sup-
posed to have an alkaline reaction, but M. Bouisson and Dr.
Kemp, who have lately made observations on tins point, state that
when fresh and perfectly healthy, it is neutral. The effects of
bile on test-papers are difficult to appreciate on account of the yel-
low stain it gives them.
Under the microscope, bile, if diluted, gives a yellow stain to
the glass, but presents no definite objects. If, on the contrary, it
be dark coloured and concentrated, it shows amorphous particles
of yellowish-green matter, which is usually collected into small
roundish masses, and is the matter obtained by evaporating the
bile.* In addition to this, a few prismatic cells from the mucous
membrane of the gall-bladder may be seen.
Perfectly healthy bile presents, perhaps, no other objects, but,
now and then, some oil- globules, or small plates of cholesterine,
are seen besides. The oil-globules are, probably, usually derived
from the lobules of the fiver. The plates of cholesterine are, it
would seem, generally, if not always, formed in chief part in the
gall-bladder, in consequence of disease of its coats. When the
coats of the gall-bladder are, as it is termed, ossified, or when the
mucous coat is much thickened or otherwise altered in structure,
the bile in the gall-bladder generally contains visible scales of
cholesterine. The bile in the hepatic ducts is less viscid, and
much less bitter, than that in the gall-bladder, and is usually of a
bright yellow, even when that in the gall-bladder is dark green or
olive-coloured. Under the microscope, it gives a fight yellow
tinge to the glass, and presents some prismatic cells, but seldom
any other object. In the numerous specimens of bile taken from
the hepatic ducts that I have examined, I have never seen plates
of cholesterine. The darker colour, and bitterer taste, of cystic
bile are, no doubt, mainly owing to its greater concentration. In
persons who have fasted some time before death, the bile in the
gall-bladder is usually very viscid and dark- coloured.
There are probably more important differences between cystic
* See Bouisson, op. cit., p. 16.
COMPOSITION OF THE BILE.
21
and hepatic bile than those which result from different degrees of
concentration, hut little is known on this point. It is very diffi-
cult to collect bile from the hepatic ducts in quantity enough for
a complete analysis, and consequently chemists, in their study of
this fluid, have confined themselves almost exclusively to bile
taken from the gall-bladder. Most chemists, indeed, have been
content with bile from the gall-bladder of the ox, which can be
more readily got in a healthy state, and can he obtained in
larger quantity than human bile.
Cystic bile contains water, the proportion of which of course
varies very much according to the time the bile has remained in
the gall-bladder, or rather, according to the degree of its concen-
tration. In the often-quoted analysis of bile from the gall-
bladder of the ox, by Berzelius, the water amounts to 904'4
parts in 1,000. The quantity of water may be readily ascertained
by evaporation.
Bile also contains mucus, derived from the gall-bladder and ducts,
the quantity of which, like that of the water, varies very much in
different specimens. In the ox-bile analyzed byBerzelius, the mucus
amounted to 3 parts in 1,000. In human cystic bile, the average
proportion of mucus is probably very much larger than this. It may
be obtained by adding to bile a sufficient quantity of alcohol, which
precipitates the mucus in flakes, while it dissolves the other princi-
ples. The mucus may also he precipitated by acetic acid. It is
chiefly to this ingredient that bile owes its viscidity. When the
mucus is in large quantity, the bile can be drawn out into threads.
Bile likewise contains a considerable proportion of soda, and
certain organic constituents, to which last it owes its colour and
bitterness. The organic constituents are very readily decom-
posed, and enter into new combinations with the substances em-
ployed to separate them. In consequence of this, different che-
mists, by employing different methods of analysis, have obtained
very different results, but all agree that these organic ingredients are
allied to fat in composition, and contain a large proportion of carbon.
The principles to which bile owes its colour may be sepa-
rated from those to which it owes its bitterness. They are en-
tirely removed by filtering bile through animal charcoal, and are
also thrown down from solution by precipitates of barytes and
other earthy salts. The green colouring matter in the bile of the
ox seems closely to resemble, if it be not identical with, the
22
INTRODUCTION.
green- colouring matter of plants. (See Graham's Elements of
Chemistry.) *
Most chemists have inferred that the organic constituents of
bile are combined in some way with the soda.
M. Demarcay has lately advanced the opinion that these essen-
tial principles of bile, abstracting the colouring matters, are in
the form of a resinous acid, (called by Liebig choleic acicl,)
which is combined with the soda, forming a substance analogous
to soaps. This view of the composition of bile brings us hack to
the doctrine which, before the elaborate analyses of Thenard and
others, was generally held, that the bile is an animal soap, whose
base is soda. This doctrine seemed sanctioned by the physical
qualities of bile — its solubility in water, its consistence, its ready
frothing, the readiness with which it takes up spots of grease or
fat— and by the fact, then known, that it contains fatty matter and
an alkali.
In addition to these constituents, bile contains a small quantity
of chloride of sodium, and most of the other salts found in the
blood.
The following is the composition of bile from the gall-bladder
of the ox, according to the analysis by Berzelius already referred
to :
Water 90 44
Biliary matter, with fat 8'00
Mucus of the gall-bladder 0‘ 30
Osmazome, chloride of sodium, and lactate of soda .... 0’74
Soda 0'41
Phosphate of soda, phosphate of lime, and traces of a
substance insoluble in alcohol 0T1
lOO'OO
* Many considerations vender it probable that the colouring matter of bile
is derived from that of the blood. A relation between the two has been long
remarked.
Saunders says, “ Green and bitter bile being in common to all animals
with red blood, and found only in such, renders it probable that there is some
relative connexion between this fluid and the coloui-ing matter of the blood,
by the red particles contributing more especially to its formation.”
Quite recently, Professor Schultz has revived this notion, and dressed
it op with much fanciful speculation. He is of opinion that in the liver
SOURCE OF THE BILE.
23
In some later researches, Berzelius lias separated from his
biliary matter a green and a yellow colouring matter, and has giveu
the name of bilin to the peculiar principle of bile. Bilin is a soft
substance of a light yellow colour, without smell, and having a
hitter and at the same time a sweetish taste. It is soluble in
water and in alcohol, and when obtained by evaporation from
alcohol, reddens litmus paper. It is readily metamorphosed by
various agents, and especially by heat and acids.
In the analyses of Demargay and Liebig, the bilin of Ber-
zelius is represented by choleic acid, which, like those matters,
enters very readily into new combinations.
Choleic acid is a compound of nitrogen, and, according to De-
ni argay, its ultimate composition is as follows : *
Carbon 63'707
Hydrogen 8'82l
Nitrogen 3 ‘25 5
Oxygen 24'217
100-000
Most chemists have obtained from bile a small quantity of
cholesterine. In certain states of disease, cholesterine exists in
large quantity in the bile of the gall-bladder, forming the chief
part of most gall-stones, but in healthy bile it is in very small
quantity, and in solution. It is not seen under the microscope.
The bile, in man, has been supposed to he ultimately derived from
two sources. It is clear enough that, in most circumstances, a large
proportion of the proper principles of bile are derived from the
waste of the body, and are a product of the metamorphosis of
the blood sheds the colouring matter of the effete blood corpuscles, and thus
becomes revivified.
Bouisson, again, says, “ Burdach fait observer, que lorsqu’il se forme du
sang rouge dans l’oeuf de poule, le jaune fixe au feuillet muqueux acquiert
une coloration verdatre, en sorte qu’il reste demontre qu’il y a coincidence
entre ia sanguification et la separation d’une matiere verte.”
* In a late No. of Muller’s “Archiv.,” is a communication from Dr. Platner,
of Heidelberg, stating that he has succeeded in obtaining the electro- negative
body, which is supposed to be the essential constituent of bile, in a state of
crystallization, both pure and in combination with soda. (Muller’s “Archiv.”
Heft. ii. 1844.)
24
INTRODUCTION.
the tissues and of materials stored away in the system. In the
carnivora, in the hybernating animal in its winter sleep, and in the
foetus, these materials must he its only source. And under cer-
tain conditions, the same must be the case in man also. In pro-
tracted abstinence, for example, bile continues to be formed, and
often in large quantities. Here, the living tissues gradually waste
away, and their materials are discharged in the excretions. The
three principal outlets at which they make their appearance, are
the liver, the lungs, and the kidney. Nitrogen predominates in
the compounds which escape through the last-named organ, while
the two former separate principally hydrogen and carbon. But
while the liver and lungs have thus much in common, there is
this important difference between them ; that in the lungs, the
hydrogen and carbon pass off burnt — that is, in combination with
oxygen, as water and carbonic acid, — while, in the liver, they
escape uncombined with oxygen, and still combustible. From
which it would appear, that the larger the amount of these ele-
ments discharged by the lungs as water and carbonic acid, the
less, ceeteris paribus, must remain unburnt to form constituents of
bile. So that here, we already meet with a fundamental and im-
portant relation between the secretion of bile and the great
function of respiration. I shall not, however, dilate upon this
topic now, as in endeavouring to follow the bile to its final des-
tination, we shall again have to consider relations of a similar
kind.
To return from this digression, it appears, then, sufficiently
clear, that the proper principles of bile are in great part derived,
like those of the urine, from the waste of the tissues. But it
seems probable, that in man, and in all animals which live on a
mixed diet, those articles of food which are devoid of nitrogen,
also contribute to the elements of bile. Liebig, indeed, imagines
that, as regards the horse and ox, he has fully established this by
means of quantitative analysis, — showing that the bile these
animals secrete in a day, contains more carbon than all the albu-
men, fibrin, and casein of their food (the protein-elements of
modern chemists) put together; more carbon, therefore, than can
be derived from the waste of the tissues which these elements go
to repair. And that, consequently, the remainder, at least, must
needs be furnished immediately by the food, aud by those con-
stituents of it, such as starch and sugar, which contain no
QUANTITY OF BILE SECRETED.
25
nitrogen. If this he so, there is every reason to presume that
these same principles, which form a large and staple ingredient in
the food of man, play in him, too, the same part.
But the calculations of Liebig are open to very serious, if not
fatal, oh j ections. The calculations are founded on the supposition
that a horse or an ox secretes daily thirty-seven pounds of bile,
as concentrated as that usually found in the gall-bladder. This
would yield about forty ounces of carbon ; whereas the animal con-
sumes in the form of vegetable albumen, fibrine, and casein, only
about four ounces and a half of nitrogen, which, reckoning from
the known composition of these substances, would give not quite
sixteen ounces of carbon. The carbon of the bile is, therefore,
greater in amount than all the carbon in the protein-elements of
the food, in the proportion of 40 to 16. This is the argument.
Its weight all depends on the truth of the assumption, that thirty-
seven pounds of bile, as concentrated as that usually found in the
gall-bladder, are secreted daily — an assumption, which, without
much stronger evidence of its truth than we have at present,
surely ought not to be made the basis of important doctrines
which, confessedly, rest solely on relations of quantity. Con-
sidering the size of the gall-bladder of the ox, thirty-seven pounds
seems an enormous quantity of bile to he secreted in a day,
and if the daily secretion should turn out to he only quarter the
amount, and few physiologists, we imagine, would rate it nearly
so high even as this, the argument falls to the ground.*
It is clear that before we can draw any safe conclusions on this
point, or trace the bile to its ultimate destination, by means of
quantitative analysis, we must have some estimate of the quantity
of bile daily secreted under ordinary circumstances. This must
necessarily he one of the starting points in any such inquiry.
Many attempts have been made to estimate the quantity of bile
* The hypothesis, that a horse or an ox secretes thirty-seven pounds of
bile in a day, has no other foundation than a calculation by Schultz, that, in
an ox, it would take as much bile as this to neutralise the acid of the chyme.
It is strange that Liebig should have adopted the estimate so unhesitatingly
on the authority of Burdach, who not only states this to be the ground of it,
but also draws the inference, that if the estimate be correct, and the ox
secrete daily ten pounds of saliva, the quantity Schultz supposed to be
secreted by the horse, the quantity of the two fluids secreted in a day would
together equal the whole mass of the blood ! (See Burdach’s Physiologie,
t. vii. p. 439.)
26
INTRODUCTION.
daily secreted by a man in a state of health, hut, as might have
been expected, the conclusions come to are wide apart, and little
confidence can he placed in the greater number of them. Some
physiologists, believing the bile to be chiefly excrementitious, and
looking to the small size of the gall-bladder and the small
quantity of bile ordinarily discharged from the bowels, have esti-
mated it at a very few ounces; while others, regarding the large
size of the liver, and believing that most of the bile secreted
is again absorbed from the bowel to serve ulterior uses in the
body, have rated it, with Burdach and Haller, at from seventeen to
twenty-four ounces.
It is clear that the amount of the proper principles of bile
secreted in a day must, like that of urinary ingredients, vary
widely in different persons, and in the same person under different
circumstances. Thus, from what has already been said, it must
vary with the activity of respiration, and with the quantity and
quality of the food. Probably, too, with the amount of perspi-
ration, or with the quantity of matter thrown off by the skin.
In some circumstances, a quantity of bile, as large as the
estimate of Burdach or Haller, may certainly be secreted for a
considerable time together. A very interesting case showing this
was read to the Medico- Chirurgical Society during the spring of
the present year, by Mr. W. K. Barlow, of Writtle, Essex.
A strong, healthy man, a thatcher, fifty-four years of age, injured him-
self hy lifting a heavy ladder, on the 28th of August, 1843. When seen hy
Mr. Barlow, the same day, he complained of so much pain in the region of
the liver that a rupture of that organ was apprehended. He was very faint,
in a cold sweat, and the pulse could scarcely he felt. Some brandy and
water was given him, and he recovered sufficiently to be taken to his own
house, which was about three miles distant. Five grains of calomel and a
grain of opium were given him at night, and an ounce of castor oil the fol-
lowing morning, which operated and produced several natural evacuations.
On the 29th he was bled, and continued the calomel and opium, with a
dose of saline mixture, every five hours.
On the 30th it was observed that the evacuations from the bowels were
white and without bile, while the urine was dark, as in jaundice. Five grains
of blue pill were ordered every six hours.
As the pain in the region of the liver continued, the bleeding was repeated
at different times, and a blister was applied over the right hypochondrium.
1 he same medicine was continued till the 15th of Sept., when a swelling,
the size of a walnut, was observed over the region of the liver. This gradually
inci eased, and on the 9th of October, was so large and caused so much
QUANTITY OF BILE SECRETED.
27
pain from distension, that it was thought proper to tap it. Seven quarts of
fluid were drawn off, which from its colour and taste appeared to be pure
bile. The pain was instantly relieved, and the swelling entirely subsided.
The fluid collected again, and it was necessary to repeat the tapping on the
21st of the same month, when six quarts and a half of fluid were drawn off.
This fluid was analysed by Dr. Pereira, Dr. G. O. Rees, and Mr. Taylor,
and found to be composed in great part of bile. Dr. Rees guessed the pro-
portion of bile in tbe fluid to be at least eight parts in ten.
On the 31st of October he was tapped again, and seven quarts were drawn
off. On the 9th of November the operation was repeated for the fourth
time, when six quarts were withdrawn. On the 18th of November be was
taken to St. Bartholomew’s Hospital, and tapped again, when nine pints of
fluid escaped. On the 26th of November he was tapped for the last time,
when only three pints escaped. The cyst was not emptied as on the former
operation, and he suffered extreme pain from the tapping, which he had not
previously done. On the following day, bile appeared in his stools, and the
urine was lighter coloured. On the 3rd of December, the motions were of
proper colour, containing plenty of bile. The swelling gradually subsided,
and towards the end of the month he became quite convalescent. In the
beginning of February he was able to walk eight or ten miles ; and when an
account of his case was presented to the Society, appeared to be in good
health.*
It appears here that in twelve days, from the 9tli of Oetoher to
the 21st, thirteen pints of fluid accumulated in the sac. If, as
Dr. Rees believed, four- fifths of this consisted of bile, nearly ten
pints and a half of bile must have been discharged ; not very far
short of a pint a day. The quantity of fluid discharged at the
two subsequent tappings was still larger in proportion to the time,
hut of this fluid no analysis seems to have. been made.
Is a note appended to the account of this case in the Society’s
Transactions, Dr. Cursham gives references to other cases of a
similar kind. One of these, by Mr. Fryer, of Stamford, in the
fourth volume of the Medico- Chirurgical Transactions, accords in
almost every particular with the case just related, except that the
subject of it was a boy thirteen years of age, and that the quantity
of fluid discharged at the successive tappings was still larger in
proportion to the intervals. The fluid was not analysed, but had,
it is stated, the appearance of pure bile. In this case, as in the
former, mercury was given.
We should not, of course, be warranted in assuming from these
cases that the same amount of bile is secreted under ordinary
* The Medico-Chirurgical Transactions, vol. xxvii. p. 378.
28
INTRODUCTION.
circumstances ; or at any rate, in drawing from such an estimate any
important physiological inference not warranted by other reasons.
In secreting bile, the liver serves unquestionably very important
purposes. The large size of the organ, and its existence in all
animals, down almost to the lowest in the animal scale, leave no
doubt on this point. But when we come to details, our knowledge
of the whole matter is found to be much wanting in precision.
One of the purposes served by the liver in secreting bile, per-
haps one of the most important purposes, is to purify the blood by
separating from it noxious and effete principles. There has been
much debate among physiologists, whether the principles of bile
are formed in the liver, or are not rather merely separated by this
organ from the blood, in which, under this supposition, they are
supposed to exist, ready-made for secretion. Data are yet want-
ing for the complete solution of this question. But it is quite
clear that the colouring matters of the bile exist in the blood,
since if they be not separated from it by tbe liver, as sometimes
happens when the secretion of bile is suppressed, the person is
speedily jaundiced.
The liver tends in another way to maintain the purity of the
blood, by ridding it of other matters foreign to its composition.
It will be remembered that all the blood sent to the stomach and
intestines has to pass through this organ before it can again mix
with the venous blood from other parts of the body. Now the
blood that has come from the stomach and intestines must neces-
sarily be charged with many impurities besides those derived from
the mere decay of the tissues. Along the extensive mucous tract
with which everything we eat or drink is brought in contact, ab-
sorption is constantly going on, and various matters must, there-
fore, enter the portal vessels, not fit by their nature to form blood,
or to serve any other purpose in the body. Many of these sub-
stances are removed from the blood in its passage through the
fiver. The discharge of such matters through the fiver, when
they are in unusual quantity, or of a particular kind, is, no doubt,
tbe primary condition of many biliary disorders.
But the bile is far from being a merely excrementitious fluid.
Arrived in the intestine, it has important offices to serve, as in-
deed might already be surmised from its being poured into this
canal so near its upper end. These offices are related to the func-
USES OF THE BILE.
29
tion of digestion on the one hand, and (according to Liehig) to
that of respiration on the other.
It was formerly supposed that the one great use of the bile
was to complete the process of digestion, and for this end it was
considered quite as essential as the gastric juice itself. That the
bile has, indeed, an important relation to digestion, is evident from
the presence in man and other animals that feed at intervals by
large meals, of a gall-bladder, which allows bile to accumulate
when the stomach and duodenum are empty, so as to be poured
into the digestive canal in greater quantity when they are full.
But there can be no doubt that the part which bile plays in diges-
tion has been over-rated. The recent investigations of chemists
have much simplified our views of this process. Since the im-
portant discovery, that the greater part of the staminal principles
of our food, whether animal or vegetable, are identical with the
constituents of blood, all that appears necessary to digestion, as
far as mere chemical changes are concerned, is to effect their solu-
tion. Now experiments of conclusive kind have shown that the
gastric juice is sufficient for this object. Starch, sugar, and
their equivalents, are soluble, of themselves, in the fluids found in
the stomach and intestines. Fat, however, is not altered by the
gastric juice, and is not soluble in the fluids found in the intesti-
nal canal, and must require, therefore, some preparation in order
to become easily absorbed : for membranes absorb with great
difficulty those fluids which do not penetrate them by imbibition,
or which, in more familiar phrase, do not wet them. There are
many reasons for believing that the fatty matters we take as food
undergo the needful modification in mixing with bile.
The experiments first performed by Brodie, and repeated by
several physiologists, show that if the flow of bile into the duodenum
be prevented by tying the ductus communis in a living animal,
and the animal be killed some time after, the chyle in the thoracic
duct will generally be found thin and serous, containing much
less than the usual proportion of fatty matter. The fact too, long
noticed by physicians, that when the common duct is obstructed
by a gall-stone, or otherwise, the patient rapidly loses his fat,
sanctions the inference. The soda of the bile, in its passage
through the intestines, is absorbed, together with the fatty matter,
by the lacteals. It is not found in the excrement, but exists in
abundance in the chyle.
30
INTRODUCTION.
Another effect commonly attributed to bile is that of neutra-
lizing the acid that passes from the stomach into the intestines,
after having performed its part in digestion. The chyme is acid
as it enters the duodenum, hut gradually loses its acidity in its
passage through the small intestine, after it has been mixed with
the bile. It is no valid objection to this doctrine that healthy bile
is neutral, since the bile might he decomposed in its passage
through the bowels. But if the soda of the bile unite with the
acid of the chyme, the characters of the bile as a soap must be
destroyed, and, consequently, the bile cannot at the same time
perform this office and promote the absorption of fatty matters in
the way usually supposed. The quantity of soda in the bile
seems, moreover, to he too small, even if it were all employed for
this purpose, to neutralize the acid of the chyme.* The chyme is
most probably neutralized, at least in part, by the secretions of the
intestinal canal. The bile may contribute to it also indirectly, by
stimulating the coats of the canal, and rendering their secretion
more active.
Whether, by virtue of its bitter quality, bile prevents, as some
suppose, the fermentation of the chyme, and the putrefaction of the
residue of digestion, is open to question. From the readiness
with which bile itself undergoes decomposition, such an office
would seem improbable. Nevertheless, it is well known, that one
of the first effects of jaundice is, that the stools become unusually
fetid, and the bowels very flatulent.
Collaterally, the bile forwards in various ways the great busi-
ness going on in the alimentary canal. One of the most obvious
of its uses is, to promote the due discharge of the contents of the
bowel. If such a phrase may he used, — bile is the natural pur-
gative. If poured into the intestine in too large quantity, it
causes diarrhoea, and if by a gall-stone, or otherwise, its flow
he stopped, constipation generally follows. Eberle further ob-
served that in animals, which he made the subject of experiment,
and especially in such as had fasted for some time before death,
the mucus of the intestine was much more abundant, as far as bile
had reached, than below this point.
We have next to consider the final destination of the bile itself.
It was tbe supposition, that the office of the bile is to neutralize the acid
of the chyme, that led to the extravagant estimate by Schultz before referred
to : viz., that an ox secretes daily 371bs. of bile.
USES OF THE BILE.
31
It seems clear that, in man, under ordinary circumstances, the
bile which is evacuated hy the bowel, can he but a small propor-
tion of the whole amount secreted. For the quantity thus voided
is very trifling, and consists chiefly of its colouring matter. The
remainder, and larger part, must, therefore, he re-absorbed.
Liebig states, that, in the carnivora, the whole of the bile is re-
absorbed. The excrements of these animals contain neither bile
nor soda ; for water extracts from them no trace of any substance
resembling bile, and yet bile is very soluble in water, and mixes
with it in every proportion. It has been lately advanced by
Liebig, on the authority of quantitative analysis, that the portion
of bile re- absorbed is eventually discharged through the lungs as
carbonic acid and water ; thus supplying fuel for respiration and
supporting animal heat. On account of the novelty and im-
portance of this doctrine, and the high reputation of its author, it
is right that the calculations on which the doctrine is based should
be closely examined.
Liebig adopts the estimates of Haller and Burdach, that a man
in health secretes daily from 1 7 to 24 ounces of bile ; and he
assumes that this bile contains 90 per cent, of water, which gives
from 816 to 1152 grains of dried bile.*
Now Berzelius found in 1,000 parts of fresh human faeces, only
9 parts of a substance similar to bile. Reckoning from this pro-
portion, the daily faeces of a man, which do not, on an average, weigh
more than 5^ ounces, contain only 24 grains of dried bile at most.
So that, according to this computation, the whole quantity of
bile secreted exceeds the quantity that can he detected in the
matters discharged from the alimentary canal in at least the pro-
portion of 816 to 24, or 34 to 1 .
The chief part of the bile is, therefore, re- absorbed, and as
(Liebig argues) no traces of it are found in the other excretions,
the hydrogen and carbon it contains must evidently be discharged
through the lungs in union with oxygen, as carbonic acid and
water. Whatever intermediate purposes it may serve, this must
he the ultimate fate of these, its chief elements.
The estimate of the amount of bile daily secreted, — namely,
from 17 to 24 ounces, as concentrated as bile usually found in the
gall-bladder, — is higher than most physiologists would admit.
* See “ Liebig’s Organic Chemistry, in its Application to Physiology and
Pathology” — pp. 64, 5.
32
INTRODUCTION.
But tlie proportion it gives of bile secreted to that found in the
excrement, is so large, that even a considerable error in this
direction would not vitiate the conclusion, although it would,
of course, give too high an estimate of the amount of fuel
for respiration famished from this source. Even at tins esti-
mate, the carbon furnished by the bile would he hut a small
proportion of that given out in respiration. It has been com-
puted that in a grown-up person, taking moderate exercise,
13_^. oz. of carbon escape daily through the skin and lungs as
carbonic acid. (Liebig, a. c., p. 14.) Now 816 grains of dried
bile, which does not contain more than 69 per cent of carbon, gives
only 563 grains of carbon, or about li oz.# These considerations
tend to show that it can hardly he one of the chief purposes of the
bile to support respiration, although it seems established by the
reasoning of Liebig, that the bile that is re-absorbed, after having
served other uses, is applied to this purpose, for which, indeed, it
seems singularly fitted by its solubility and the large amount of
carbon and hydrogen it contains.
Many physiologists, however, still hold to the old opinion that
the bile is mainly excrementitious, and is voided by the intestine.
In their view, the great office of the liver is to rid the system of
all matters rich in hydrogen and carbon that result from the waste
of the tissues, and are not discharged by the lung in union with
oxygen. These organs are thus considered to be directly and
strictly vicarious in their office, and in support of this view it is
alleged that, throughout the animal scale, whenever the lungs are
large and active, the liver is small, and vice versa. Thus, it is re-
marked, that in all cold-blooded animals — creatures in which re-
spiration is very feeble — the liver is very large and excessively
developed when compared with the lungs. But it is a very formid-
able objection to this vicarious theory, that in serpents, whose re-
spiration is extremely feeble, the excrement does not contain a
particle of bile. Great stress is laid on the case of the mollusca,
animals whose liver is generally immense in proportion to their
other viscera. But even if their bile he excreted, that would not
disprove Liebig’s theory of the use of bile in man and the higher
* Liebig has made a calculation of this kind with reference to the ox, and
concludes that in that animal the bile daily secreted contains 40 ounces of
carbon, hut he starts with the extravagant estimate of 371bs. (as concentrated
as that in the gall-bladder) for the amount of bile daily secreted.
USES OF THE BILE.
33
animals, since this professes to rest on entirely independent evi-
dence. The same may be said with regard to the instances of animals
in which the bile is poured into the rectum, and is, therefore, pro
bably voided by the intestine.
Thus it appears, on any supposition, that the relation of bile
to respiration is direct and fundamental. Fortunately, the activity
and effects of the respiratory process are largely under our control.
In the vast power we have of modifying these by appropriate re-
gulations, having reference to the great conditions of air, exercise,
temperature, and food, we have means much more effectual than
any other, in dealing with biliary disorders.
Of these disorders, on the other hand, the neglect of such re-
gulations is by far the most fruitful source.
Thus, for example, may he explained many of the bilious dis-
orders of hot climates. If, in such climates, the food he not
regulated in accordance with the smaller needs of the economy as
to animal heat, an excess of bile is formed, and disorder of the
stomach and intestines — bilious vomiting, and diarrhoea — are the
consequence.
Hence, also, the general repugnance to rich meats, and the
greater tendency which these and spirits unquestionably have
to produce disease of the liver, in hot seasons and in tropical
climates.
In the same way may be explained the greater frequency of
bilious disorders in middle life, when men begin to take less exer-
cise, and their respiration becomes less active, while on the
other hand, the tendency to indulgence at table hut too often
increases.
We may also often see inverse evidence of these relations in the
effect of pure air and active exercise, in relieving various disorders
that result from repletion, and from the retention of principles,
which if not burnt in respiration, should pass off by the liver as
bile. Every sportsman must have remarked the effect of a single
day’s hunting in clearing the complexion. It has, no doubt,
much the same effect on the liver, as on the skin.
These, however, are not the only conditions that influence the
secretion of bile, and its tendency to accumulate in the system.
This must also depend on the state of the liver itself, and espe-
cially on the number and activity of the cells in its lobular sub-
stance.
u
34
INTRODUCTION.
Not unfrequently, in bodies examined in our hospitals, consider-
able portions of the liver are found atrophied, from adhesive in-
flammation in or about branches of the portal vein. In conse-
quence of the obstruction of those vessels, the portions of liver to
which they carried blood, waste, and if those portions be near the
surface, the capsule is drawn iu, and the surface appears puckered,
or fissured, according to the size and direction of the obstructed
veins. Again, hydatid and other tumours may cause atrophy of
portions of the liver, by the pressure they exert on its substance,
or on the vessels which supply it.
But in effect of acute disease, without any permanent obstruction
of vessels, the vitality of the cells may be permanently damaged,
and their power of reproduction perhaps impaired.
In persons who die of yellow fever, the liver presents various
morbid appearances, which have been minutely described by Louis,
that depend not on the products of inflammation, or on the state of
the vessels, but on the condition of the cells. The damage done to
the liver in this way may last for years. It is probable that the
bilious disorders of many men on their return to this country from
India and other hot climates are in great measure owing to perma-
nent injury done to the secreting element of the liver.
In most persons, perhaps, a portion of the liver may waste or be-
come less active, without sensible derangement of health. They
have more liver, as they have more lung, than is absolutely neces-
sary. In others, on the contrary, the liver, from natural con-
formation, seems only just capable of purifying the blood from the
principles of bile, in favourable circumstances. They are born
with a tendency to bilious derangements. This innate defect of
power in the liver has its counterpart in the deficient respiratory
power in persons with vesicular emphysema of the lungs, and
like this latter defect, and most other peculiarities of physical
structure, is no doubt frequently inherited. People who in-
herit this feebleness of the liver, if we may so term it, or
in whom, in consequence of disease, a portion of liver has
atrophied, or the secreting element of the fiver has been da-
maged, may suffer little inconvenience as long as they are placed
in favourable circumstances, and observe those rules which such
a condition requires ; but whenever from any cause — as a hot
climate, gross living, indolent habits, constipation — a more
abundant secretion of bile is requisite to purify the blood, the
CHOLAGOGUE MEDICINES.
35
liver is inadequate to its office, and they become bilious and
sallow. In the management of such cases, we have two objects
to fulfil — 1st, to enjoin those conditions and rules of life, that
render a plentiful secretion of bile less needful ; and 2nd, to en-
deavour to render the liver itself more active.
The chief conditions to diminish the quantity of matter which
the liver is called on to excrete, are a light diet, with water for
drink; active exercise; early rising; and a cool, or temperate
climate. Acids have been supposed to act in the same way, and
have been much in repute as a remedy in liver disorders, particu-
larly in India, where, from the circumstances mentioned, a remedy
having this mode of action is especially required.
Various medicines seem to fulfil to a certain extent the 2nd
object, that of rendering the liver more active, and increasing in
this way the secretion of bile. Mercury, iodine, muriate of am-
monia, and taraxacum, have undoubtedly an action of this kind.
The first and the last of these medicines, especially, have long-
been in this country the chief resources of the physician in the
treatment of chronic hepatic disorders. The marked temporary
benefit often resulting from mercury given for this effect has, from
the difficulty of distinguishing the various diseases of the liver,
and the consequent indiscriminate use of the drug, led to great
evils. This medicine was at one time, by English practitioners,
given almost indiscriminately, and long persevered in, for disorders
of digestion, many of which did not depend on fault of the liver at
all, but on local disease of the stomach or intestines, or on faulty
assimilation, the result of debility, which the prolonged use of the
mercury but too often increased. Of late, these evils have much
abated, but still, before the diagnosis is rightly made, mercury
is often tried in cancer, and other incurable organic diseases of
the liver, in which this and other powerful and lowering remedies
can only do harm.
Pepper, ginger, and other hot spices, are also supposed, perhaps
justly, to render the liver more active, and increase the secretion
of bile. The great relish with which they are eaten by our coun-
trymen in the East and West Indies, gives considerable sanction
to this opinion.
Most purgatives, but especially rhubarb, have perhaps an effect
of the same kind, and may fitly be styled in the language of our
fatheis, cholayogues. Many persons have succeeded in warding
D 2
3G
INTRODUCTION.
off bilious attacks to which they had been long subject, by taking
habitually before dinner a few grains of rhubarb. A rhubarb
pill will often relieve a slight bilious disorder, even before it has
purged.
We may suppose these medicines to excite the secretion of the
liver, either by virtue of the impression they make on the stomach
and duodenum, or by their becoming absorbed in the stomach and
intestines, and subsequently excreted by the liver. Spices pro-
bably act chiefly in the former way, and excite the secretion and
flow of bile, as they do that of saliva, by the impression they
make on the mucous membrane adjacent. Mercury, iodine, and
other medicines, probably excite the secretion of the liver chiefly,
if not solely, by becoming absorbed into the blood, and passing
out of the system with the bile.
We have, indeed, little positive evidence in favour of this
theory, by regarding the liver merely, because not many analyses
of any kind have been made of human bile ; and very few at-
tempts have been made to discover different medicines in it.
Authenrieth and Zeller * state that they found mercury in the
bile of animals treated by mercurial frictions. Bouissonf states,
that the colouring principles of madder and some other sub-
stances pass off in the bile ; a fact which, if established, would
lead us to expect that some principles of rhubarb and taraxa-
cum might pass off in it likewise. Iodine, I believe, has not
been found in human bile, but from its escaping so readily as it
does in most other secretions, and from its being found in con-
siderable quantity in the liver of the cod and other fish, we may
expect to find it in the bile of persons who die while taking it.
Most medicines that act as diuretics are, no doubt, excreted by
the kidneys. Nitre, iodide of potassium, asparagus, and most
other medicines of diuretic action, for which we have tests, or
which we can detect by our senses, have been found in the urine.
The active principle of squills, our chief expectorant, probably
passes off by the lungs, for all the onion tribe, of which squills is
one, taint the breath. It would seem, indeed, not only that most
medicines that increase the secretion of a gland, pass out of the
system through it, but conversely, that nearly everything foreign
* Bouisson, p. 14, who takes this fact from ReiPs. Archiv. fur die Physio-
logic, vol. viii. p. 252 ; 1807, 1S08.
t Id. p. 303.
10
CHOLAGOGUE MEDICINES.
37
to its own secretion, that drains off' through a gland or mucous
membrane, excites its secreting function. #
Medicines that pass off in this way through a gland, not only
increase the flow from it, but may also alter the qualities of the
secretion, and act directly, on the surfaces over which the secre-
tion passes ; and when the secretion is unhealthy or these sur-
faces are diseased, these latter effects of the medicines may be far
more important than the first.
We have examples of this in the efficacy of alkalies in prevent-
ing the deposit of lithic gravel in the urine ; and in that of the
balsams and of various vegetable astringents, in certain diseases
of the bladder and urethra. As might have been expected, our
knowledge of the effects of different medicines on the qualities of
the bile, and on the mucous membrane of the gall-bladder and
ducts, is very scanty. We cannot ascertain during life the com-
position of the bile, and of course cannot tell in what way, or in
what degree, our medicines change it. But there are, unquestion-
ably, medicines which do change it. Experience long ago led
physicians to infer that if some medicines, as mercury, owe their
chief virtue, in hepatic disorders, to their increasing the quautity
of the bile, there are others, whose chief merit consists in their
altering its quality. Alkalies, — especially soda, — ether, and turpen-
tine, have been supposed to render the bile thinner, and have, on
this account, been, at various times, recommended as remedies for
gall-stones. Hitherto, it has been impossible to fix the value of
medicines of this class. They are given empirically, generally
with a vague notion only of what is amiss, and according to the
chances of individual experience, or the fashion of the day, are
rated at one time much above their worth, and at another time, in
effect probably of this very over-estimate, are altogether discarded.
Medicines which alter the urine, or act on the bladder or
urethra, have more permanent favour, because, from being always
able to collect and analyse the urine, we have better opportunities
of fixing their value.
* On the same principle, undoubtedly, various abnormal matters that find
their way into the portal blood, cause sudden and copious fluxes of bile. —
Cruveilhier has some good remarks on this in his “ Anatomie Pathologique.”
CHAPTER T.
CONGESTION OF THE LIVER.
Congestion of the liver from impediment to the flow of blood
through the lungs or heart — Effects of tins — Congestion from
other causes — Portal-venous congestion.
The liver, from being occupied by a close plexus of capillary
vessels, which is supplied with blood, already retarded by passing
through a capillary system, is peculiarly liable to congestion, —
that is, to an accumulation of blood in its vessels, — when, from
organic disease of the heart, or acute disease of the lung, the
course of the blood through the chest is impeded.
The liver presents different appearances, according to the degree
of congestion.
In slight degrees, the twigs of the hepatic vein and the capillaries
that terminate in them, are found, after death, turgid with blood, while
the portal twigs, and the capillaries that immediately spring from
them, are empty. A section of the liver presents, in consequence,
a mottled appearance. The central portions of the lobules, where
the vessels are congested, form isolated red spots, while the margins
of the lobules, where the vessels are empty, have a colour which
varies from yellowish-white to greenish, according to the quantity
of oil-globules and of colouring matter which the cells contain.
This appearance has been termed by Mr. Kiernan, the first stage
of hepatic-venous congestion. When the course of the blood
through the heart or lungs is impeded, the hepatic veins and the
capillaries that open into them are naturally the first to become
turgid.
In a further degree of congestion, more of the vessels forming
APPEARANCES PBODUCED BY CONGESTION.
39
Fig. 9.
Rounded lobules on the surface of the liver, in the first stage of hepatic-
venous congestion. A, centres of the lobules, red from congestion of the
hepatic twigs and adjacent capillaries ; C, margins of the lobules, pale, from
the capillaries there not being congested ; B, spaces between the lobules,
occupied by twigs of the portal vein. (After Kiernan )
die capillary network are filled, of course in a direction backward,
towards the portal vessels. The congestion extends from lobule
to lobule, at those points where the adjacent lobules are connected
by their capillaries ; and when the congestion has nearly, but not
quite, reached those twigs of the portal vein that go to define the
lobules, all the capillaries of the lobules will be injected, except-
ing those immediately surrounding the portal twigs. A section
of the liver will still present a mottled appearance, but now the pale
portion will be in spots, where the uninjected twigs of the portal vein
are divided, and the red portion will form a band continuous through-
out the liver. This appearance is what Mr. Kiernan has called the
second stage of hepatic-venous congestion.
A liver congested to this degree is enlarged from the large quantity
of blood it contains ; and, as Mr. Kiernan has remarked, it is fre-
quently at the same time in a state of biliary congestion. The
biliary congestion is an accumulation of biliary matter in the lo-
bules of the liver, giving the uninjected portions of the lobules a
deeper yellow or greenish tint than is natural to them. It seems to
be a consequence of the congestion of blood, and is produced
perhaps in great measure by impediment to the free escape of the
bile through the small ducts, from the pressure exerted on them by
the distended vessels.
40
CONGESTION OF THE LIVER.
Fig. 10.
c.
Lobules on the surface of the liver, in the second stage of hepatic-venous
congestion. A, centres of the lobules, red from congestion of the hepatic
twigs and adjacent capillaries ; C, places where capillaries uniting contiguous
lobules are congested ; B, pale spots, where the capillaries springing from
the portal twigs are uninjected. (After Kiernan.)
In a still higher degree of congestion, the portal vessels like-
wise are found filled after death, and the whole liver is red, hut, as
was observed by Mr. Kiernan, the central portions of the lohules
are of a deeper hue than the marginal portions.
It is only when the vessels are so turgid, that the liver is en-
larged, or the secretion and discharge of hile are somewhat impeded,
that the congestion can be considered morbid.
Simple congestion, perhaps, renders the liver more friable, but
this change of consistence is not very appreciable. The chief
anatomical characters of congestion, are the deep colour of the liver
and its increased size.
Enlargement of the liver must take place in some degree in all
cases where the vessels are turgid, but the degree of enlargement
will depend on the time the congestion has lasted, and on the
previous condition of the liver. The longer the vessels are kept
distended, and the more yielding the other tissues, the greater, of
course, will be the enlargement. In young persons, and in
persons in whom the liver is healthy, and its capsule thin, the
liver will necessarily enlarge much more for a given force of dis-
tension, than in persons in opposite circumstances. When the
liver has become unnaturally firm and tough by the interstitial
EFFECTS OF PASSIVE CONGESTION.
41
deposit of new fibrous tissue, an impediment to the free passage
of blood from it towards th& heart, unless it be long-continued,
will produce but little increase of its size ; but it will exert the
same, or even greater, pressure on the other elements of its texture,
and be as apt, therefore, or even more apt, to cause secondary biliary
congestion.
The most frequent opportunities we have of observing the
effects of simple congestion of the liver, are in persons labouring
under organic disease of the heart. It often happens, that in such
persons, when the circulation is more than commonly impeded,
the liver grows larger. Its edge can be felt two or three inches
below the false ribs. If the circulation be relieved by bleeding,
or by diuretics, or by rest, the liver returns to its former volume.
This enlargement of the liver from congestion, often takes place,
and again subsides, very rapidly, according to the varying condi-
tions of the general circulation.
In estimating the bulk of the liver, iu congestion and other
diseases, we must bear in mind, that its natural limits vary
with posture and many other circumstances. It descends an
inch or two lower when the person under examination is standing
or sitting, than when he is lying down ; it is lower after in-
spiration, than after expiration ; and it may be pushed down by
fluid in the cavity of the pleura, or by bloated, emphysematous
lung.#
Enlargement of the liver from congestion is, in general, un-
attended with pain, and the only complaint the patient makes is
of a sense of weight, or fulness, in the right hypochondrium.
Occasionally, these symptoms are succeeded by a slight tint of
jaundice. As the blood, when its passage through the lungs is
impeded, is imperfectly decarbonized, and gives a purplish
colour to the face, — so, when its course through the liver is im-
peded, the blood is not completely freed from the principles of bile,
and the countenance acquires a slightly jaundiced, or sallow tint.
When both organs are congested at once, as happens when the
flow of blood through the left side of the heart is obstructed, both
effects sometimes follow, — the complexion becomes purplish, and,
at the same time, sallow. This hue of the complexion, in cases
of obstructed circulation, has been distinctly noticed by Dr.
Bright. He says : “ Wbcn obstruction takes place to the circu-
* Andral’s “Clinique Mcdicale,” t. iv. p. 108.
42
CONGESTION OF TIIE LIVER.
lation through the chest, but more particularly when the heart
becomes over- distended with blood, we observe the countenance
gradually assume a dingy aspect, in which the purple suffusion of
carbonized blood is mingled with the yellow tint of slight jaun-
dice : the conjunctiva is more decidedly tinged ; and, if the dis-
ease continue long, sometimes completely prevails over the purple
tint.”
This jaundiced tint of the complexion, co-exists with a jaun-
diced condition of the liver itself, or, as Mr. Kiernan expresses it,
with biliary congestion, which has been already noticed as some-
times consequent on sanguineous congestion.
If the biliary congestion he long kept up, the function of the
cells in the congested lobules is arrested, or rendered less active,
and the cells become perhaps impaired in their vitality and powers
of reproduction.' The liver is permanently injured in its se-
creting element, as it is when the common duct has been long
obstructed.
Andral and most other writers have remarked that congestion
of the liver from a mechanical cause, when long continued, often
leads to organic disease of the liver ; and they have explained in
this way the frequent association of organic disease of the liver
with organic disease of the heart. The changes in the liver,
really attributable to disease of the heart, consist, at first, in dis-
tension of the capillary blood-vessels, and in accumulation of
biliary matter in the lobules, — in consequence, probably, of im-
pediment to its escape through the small ducts. If this im-
pediment be kept up, the biliary matter, as long as there are
cells enough to separate it from the blood, goes on accumulating
faster than it can escape ; hut whenever the cells are long pre-
vented from discharging their contents, they seem to lose their
fertility, and, consequently, diminish in number. Further on,
cases will be related, where, from the flow of bile having been
long obstructed by closure of the common duct, the liver had
entirely lost its lobular appearance, and contained no nucleated
cells; so that, when a portion of it was examined under the
microscope, nothing was seen but free oil-globules and irregular
particles of greenish or yellow biliary matter.
Most writers have stated that disease of the heart produces
cirrhosis of the liver ; meaning, by this term, the hardened and
granular state of the liver so frequently found in drunkards,
OTHER KINDS OF CONGESTION.
43
which is produced by the interstitial deposit of librine from ad-
hesive inflammation, and which often produces accumulation of
biliary matter in the lobules, — probably by preventing, like con-
gestion of the liver, its escape through the small ducts. But
disease of the heart does not, it would seem, of itself, lead to
this form of disease, or indeed to inflammation of any kind.
Among the many persons who die in our hospitals of diseased
heart, consequent on rheumatism, we seldom find the liver tough
and granular, from newly formed fibrous tissue, except in such of
them as have drunk spirits to excess. But although disease of the
heart may not directly lead to inflammation of the liver, it may yet,
by causing a stagnation of blood in the vessels of the liver, give
greater effect to spirits, or any other deleterious agent absorbed
from the intestinal canal, and thus mixed with the portal blood.
This point will be again noticed in a subsequent chapter on Ad-
hesive Inflammation of the Liver.
There is little to be said on the treatment of mechanical con-
gestion of the liver. The congestion is the consequence of an-
other disease, and the treatment which relieves the latter, will
diminish the congestion. When the congestion depends on ob-
stacle to the circulation through the heart, the proper remedies
are those, — such as bleeding, purgatives, diuretics, rest, — which
most effectually relieve the heart. When the liver cannot free the
blood from the principles of bile, or the skin becomes sallow, the
patient should carefully abstain from rich meats and fermented
drinks, which would render the liver still more inadequate to its
office, and increase the bilious disorder.
Hitherto, we have considered only congestion of the liver pro-
duced by mechanical impediment to the return of blood from it,
— or, as most writers express it, passive congestion. But the
liver may be congested from other causes. Thus, in the hot stage
of ague, there seems to be, in some instances, in the liver, as well
as in the spleen, an accumulation of blood, which is not attended
with effusion of any matter characteristic of inflammation, and
which subsides when the fit of ague is past. We are ignorant of
the exact cause of these temporary accumulations of blood.
Congestion of the liver may also result from a faulty state of
the blood, quite independently of any mechanical impediment to
its course through the lungs or heart. In a person dead of
purpura hremorrhagica, I have found the liver and spleen very
44
CONGESTION OF THE LIVER.
large, and. of the dark colour of a morello cherry, from the great
quantity of blood they contained. From the late researches of
M. Anclral, it seems that a great diminution in the proportion of
hbrine is the change in the blood that most disposes to such
congestions.
The congestions of the liver in ague and from faulty states of
the blood, have to the congestion produced by a mechanical im-
pediment to the flow of blood through the lungs or heart, merely
the outward resemblance caused by distension of the vessels.
They differ from it in their causes, and are not removed or
lessened by the same means. We have a clear conception of the
way in which congestion from disease of the heart is produced,
and also of the way in which it impedes the function of the liver,
and ultimately leads to permanent change of structure — hut of the
mechanism and remote effects of these other kinds of congestion,
we know very little.
In congestion of the liver from disease of the heart and lungs,
the hepatic veins, being nearer the seat of obstruction, in the
course of the circulation, than the portal veins, are naturally the
vessels first distended ; — and when the congestion is partial, the
hepatic twigs, and the capillaries that immediately surround them,
Lobules on the surface of the liver, in a state of portal-venous congestion.
A, twigs of the hepatic vein in the centres of the lobules, surrounded by
uninjected capillaries ; C, margins of the lobules, red — from the capillaries
there being congested ; B, spaces between the lobules, occupied by injected
twigs of the portal- vein. (After Kiernan.)
Fig. 11.
PORTAL-VENOUS CONGESTION.
45
are found after death, to be the full vessels ; the portal twigs, and the
capillaries that immediately spring from them, the empty ones.
But, now and then, the portal veins, and the capillaries imme-
diately springing from them, are found alone congested. The
margins of the lobules, and the interlobular spaces are then of a
red colour — forming a continuous red band — while the centres of
the lobules appear as isolated pale spots.
Mr. Kiernan has applied to this congestion of the portal veins
only, the term portal-venous congestion. From the pale unin-
jected portion being in isolated spots, it looks very like the second
stage of hepatic-venous congestion. It is remarked by Mr.
Kieman, that the injected substance never has the deep red colour
that it has in hepatic-venous congestion.
All that we know of this form of partial congestion, is con-
tained in the few observations of Mr. Kiernan, who says, that it
is very rare, and that he has met with it in children only.
46
CHAPTER II.
INFLAMMATORY DISEASES OF THE LIVER.
Sect. I. — General remarks on the classification of Inflammatory
Diseases of the Liver — Suppurative inflammation , and
Abscess, of the Liver.
The inflammatory diseases of the liver are usually divided into
acute and chronic ; but this division is essentially faulty iu
practice, because the terms are applied, not with reference to the
kind of inflammation, or the rapidity with which it works its
effects, hut to the severity, merely, of the local symptoms. Now,
inflammation of the liver running rapidly into abscess, if deep-
seated and of small extent, may give rise to hut few and obscure
local symptoms, and would consequently he styled chronic during
the life of the patient ; while inflammation, involving the surface
of the liver, even of such kind as causes the slow effusion of
coagulahle lymph only, will he attended with well-marked local
symptoms, — with great pain and tenderness, — and would be termed
acute.
We shall never have faithful descriptions of inflammatory
diseases, or unerring rules for their treatment, until we arrange
them, not according to their mere outward characters, or the pro-
minence of particular symptoms, but according to the nature of
their causes ; for it is a truth that cannot he too strongly en-
forced, that it is the nature of the cause of an inflammatory dis-
ease, that mainly determines its course and character, and the
influence of remedies over it.
To take, for example, the inflammatory diseases of the knee-
joint
GENERAL REMARKS.
47
If inflammation of the synovial membrane of the knee-joint be
excited by a penetrating wound, and the consequent admission of
air, it causes speedy suppuration, and generally destroys the joint.
If it be occasioned by tbe presence of pus in the blood, it is
attended with very little effusion and swelling; but, as in tbe
former case, it leads to tbe formation of pus; and that so soon,
and with such slight local symptoms, that pathologists have even
inferred, that the pus, instead of being formed by a process of in-
flammation iu the joint, is actually deposited there, ready made,
from the blood.
If the inflammation be excited by the peculiar cause of rheu-
matism, it is attended with severe pain, and often with much
effusion; but tbe fluid effused is never purulent, and is almost
always absorbed after some days, leaving the motions of the joint
free, and its structure uninjured.
If the inflammation be gouty, it is attended with still more
severe pain and greater effusion ; but the fluid effused here dif-
fers in quality from the fluid effused in rheumatism ; and when
its aqueous part is absorbed, particles of lithate of soda are often
left on the synovial membrane, aud in the areolar tissue about the
joint. These, perhaps by mechanical irritation, occasion fresh
attacks of inflammation, which lead to fresh deposits of lithate of
soda, and, at length, the joint is completely crippled.
If the inflammation be excited by the specific poison of gonor-
rhoea, it is attended, like gouty inflammation, with abundant
effusion, which distends the synovial capsule, and causes great
swelling. There is seldom much pain, or fever, but the disease
is very obstinate, the swelling, in spite of all the remedies we yet
know of, often lasting weeks or months.
Thus we may have — to take the last two examples — to treat
two cases of inflamed knee. The appearance of the joint is
exactly alike in the two cases, and in both there is great swelling
from fluid effused into the synovial capsule. We give colchicum
in both : in one case, the inflammation rapidly subsides under
the remedy, and the effused fluid is quickly absorbed ; in the
other, the malady pursues its course as if nothing had been done.
And why this difference ? The parts that suffer are the same, and
the changes, in outward appearance, exactly alike in the two cases.
One might readily be mistaken for the other. The reason is
simply this: the morbid changes are, in one case, the effect of
48
SUPPURATIVE INFLAMMATION OF TFIE LIVER.
the specific principle of gout; in the other, that of the poison of
gonorrhoea ; and although they are alike in the two cases in those
characters that most strike the eye — in the distension of vessels and
the effusion of fluid — they differ in more essential particulars.
The instance here adduced is a simple one, but every depart-
ment of pathology abounds with illustrations of the same truth ;
thus leading to the conviction, that we can never foresee clearly the
result of an inflammatory disease, or foretel the effect of our
remedies on it, unless we have ascertained its cause, or know at
least the particular character of the inflammation. It is, in a
great measure, our ignorance of the causes and particular cha-
racters of the diseases we have to treat, that renders the practice of
medicine so uncertain.
At present, it would be premature to attempt to arrange the in-
flammatory diseases of the liver with reference solely to their
causes ; hut, as the nature of the cause mainly determines the
character of the inflammation and its mode of termination, some
approximation to such an arrangement will be obtained by classing
them according to their effects. I propose, therefore, to range the
inflammatory diseases of the liver under the following heads: —
1st. Suppurative inflammation, or that which leads to suppura-
tion and abscess ;
2nd. Gangrenous inflammation;
3rd. Adhesive inflammation, or inflammation that causes effusion
of coagulable lymph ;
4tli. Inflammation of the veins of the liver ;
5th. Inflammation of the gall-bladder and ducts ;
And to consider, as far as our present knowledge permits, the
various causes of these different forms of inflammation, and the
modification of each form according to the particular cause that
excites it. In following out this plan, I shall speak first of the
causes of inflammation of the liver that leads to suppuration
and abscess.
Suppurative Inflammation , and Abscess, of the Liver.
With the view of discovering the causes of inflammation of the
liver that leads to suppuration and abscess, I have tabulated the
chief circumstances of sixty cases in which one or more abscesses
were found in the liver after death. Fifteen of these cases
CAUSES.
49
occurred in my own practice at the Dreadnought, in sailors, most
of whom had been in the East; sixteen are published in the
works of Andral* and Louis, h and were most of them collected
m the hospitals of Paris; and twenty-nine are recorded in the
splendid work by Annesley, on the diseases of India.
In the following remarks frequent reference will he made to
these cases.
The most obvious cause of abscess of the liver, and which may
therefore be fitly placed first, is —
1 st. A blow, or other mechanical injury. But this is by no means
a frequent cause. In the sixty cases of abscess of the liver to
which I have alluded, there is only one — a case recorded by
Andral — in which the disease was clearly traced to a blow. In
this case (Clin. Med. tom. iv. ohs. xxviii.), there were two large
abscesses on the convex surface of the right lobe ; the usual seat,
probably, of abscesses produced in this way.
The rarity of inflammation and abscess from accidental injury,
shows how effectually the fiver, when of its natural size, is shielded
by the libs.
2nd. A second, and far more frequent cause of abscess of the
fiver, is suppurative inflammation of some vein, and the conse-
quent contamination of the blood by pus.
\ ery soon after morbid anatomy began to be studied, it was
noticed that in persons who die some days after a severe injury or
suigical operation, there are often collections of pus in the lungs,
the liver, the joints, between the muscles, and in various other
parts of the body. These collections of pus form very rapidly —
in some cases, in three or four days — and often with very slight
local symptoms ; and when occurring in the lung, are strictly
circumscribed, or immediately surrounded by perfectly healthy
pulmonary tissue.
These circumstances suggested the notion, at one time generally
received, and still held by some eminent pathologists, that the
pus is not formed by a process of inflammation in the parts in
which we find it, but that it is all brought with the blood from the
original seat of injury, and merely deposited in those parts. The
abscesses found in the lungs and liver in such cases, have, in con-
sequence, been very generally spoken of, as deposits of pus.
* Clinique Medicale, t- iv. .
1 Memoires ou Recherches Anatomico-pathologiques sur diverses maladies.
50
SUPPURATIVE INFLAMMATION OF THE LIVER.
An examination of pus through the microscope is sufficient to
show, that it cannot he deposited in the way supposed. Pus-
globules are larger than blood-globules — according to some anato-
mists, twice as large — they could not then escape bodily from the
vessels, without the blood-globules escaping as well. This circum-
stance is perhaps, of itself, sufficient proof that the pus of those
scattered abscesses is not simply deposited from the blood, but
that it is formed, as in other cases, by a process of inflammation,
in the parts in which we find it.
Other, and more conclusive, evidence on this point, has been
furnished by the researches of M. M. Dance and Cruveilhier.
They have shown that although in most of such cases we find in
the lungs fully-formed abscesses immediately surrounded by pul-
monary tissue perfectly healthy — yet in other cases, in which
death happens earlier, instead of abscesses, we find small circum-
scribed, indurated, or liepatised masses. In some instances, the
abscesses are formed in succession, so that in the same lung we
may find all intermediate stages between commencing induration,
or hepatisation, of a small circumscribed portion of the pulmonary
tissue, and a small circumscribed abscess. This circumstance, in-
deed, did not escape the observation of Morgagni.* And his sa-
gacity led him from this very near to what at present seems to be
the true mode of formation of these abscesses, +
He inferred that pus earned to the viscera from distant parts, is
* Speaking of abscesses of the same kind that result from injuries of the
head, Morgagni says —
Fac enim relegas quas tibi novissime descripsi, Valsalvae observationes.
Nempe tubercula plerumque invenies sive in pulmonibus, sive in ipso etiam
jecore non omnia fuisse suppurata, quin plura interdum glandulosi corporis
firmitudinem adhuc referenda. Quid ? si asgro moriente, necdum ulla essent
qua; pus habere inciperent.” (Epist. li. art. 23.)
His words are, — ■
“ Videtur autem secundum eas observationes, quibuscum, ut puto, Molli-
nellii conjungi potest observatio, pus in viscera aliunde invectum, non puris
forma semper deponi, sed haud raro saltern nonullas ejus partieulas cum
sanguine permistas, et prorsus disjunctas, in augustiis quibusdam, fortasse
glandularum lymph aticarum, hserere, easque, ut in venereorum bubonum
productione fit, obstruendo, aut irritando, eoque humores praeterituros reti-
nendo distendere, et multo copiosoris quam quod advectum est, puris gene-
ration!, a rigoribus illis, et horroribus significatse, causam praebere. Qua
ratione illud quoque intelligitur, quomodo multo plus puris in visceribus, et
caveis corporis ssepe deprehendatur, quam modicum vulnus dare potuisset.”
CAUSES.
51
not always deposited as pus, but that often some of its globules
become arrested in the narrow channels of the body, and there, by
obstruction or irritation, cause congestion, and give occasion to
the formation of a much greater quantity of pus than is brought
there by the blood.
The mode of formation of these abscesses is well illustrated by
an experiment made more than half a century ago by Dr. Saun-
ders, and related by him in his admirable work on the structure
and diseases of the liver. He injected 5ij. of quicksilver into the
crural vein of a dog. No ill effects were observed the first day,
but at the end of this the dog became feverish, and after two or
three days had cough and difficulty of breathing, which continued
until its death. On examination after death, Dr. Saunders found
the lungs studded with small indurated masses, which he calls
tubercles, and small circumscribed abscesses. In the centre of
each was a small globule of mercury.
Here, the globules of mercury, like the -globules of pus in puru-
lent phlebitis, became arrested in the capillary vessels of the lungs,
and each globule, acting perhaps by mere mechanical irritation,
excited circumscribed inflammation and abscess. The inflamma-
tion was circumscribed, because the irritation that excited it,
acted only at particular points.
In the dog experimented on by Dr. Saunders, the lungs were
the only organs in which abscesses were found. The reason of
this is obvious. All the mercury, conveyed directly to the lungs,
became arrested in their capillaries. No globules passed through
to cause inflammation and abscess of other organs.
In the same way, in some cases of purulent phlebitis consequent
on injury of the head or limbs, or on amputation, abscesses are
found in the lungs only; and they are usually found in the lungs
in greater number than in other internal organs. After the lungs,
the liver is the organ in which they are most frequent ; a circum-
stance attributable, in some measure, to the large quantity of blood
that flows to the liver, and to the slowness of the current through
its capillary net-work ; but, perhaps, still more, to those vital or
other attractions by which matters of particular composition are
there detained and excreted.
In the liver, the abscesses are often scattered, as in the lungs,
but they are usually larger, and less regular in their outline —
a consequence, it would seem, of the anatomical fact noticed by
j; 2
52
SUPPURATIVE INFLAMMATION OF THE LIVER.
Mr. Bowman, that the lobules of the liver are not distinct bodies,
separated from each other by a layer of areolar tissue, but that
their capillaries form a continuous network throughout the entire
organ.
For a long time it was strongly objected to the doctrine, that
the scattered abscesses consequent on injuries and surgical opera-
tions are formed in the way here supposed, that in many such
cases no inflamed vein can he detected after death.
This objection was much weakened by the important observa-
tion made by Mr. Arnott, that the effects of purulent phlebitis are
not in relation to the size of the vein, or to the extent of the por-
tion inflamed — and that even in cases rapidly fatal, the portion of
vein inflamed is often very small. Mr. Amott infers, no doubt
rightly, that in many cases we fail to discover the source of the
mischief, on account of the small size of the vein, or the small
extent of the portion inflamed.
Another important observation has been made by Cruveilhier,
which almost entirely removes the objection I have stated. It is,
that after operations or injuries, where a bone has been divided or
broken, the portion of vein inflamed, the source of the subsequent
mischief, is often within the hone. He maintains that operations
and injuries that involve bones, are those most frequently
followed by scattered abscesses ; and that inflammation of the
veins in the interior of hones is more apt to cause them, than in-
flammation of the veins of other textures.
He accounts for this by the circumstance that the vascular
canals of bone cannot collapse like the vessels of other textures ;
and further supports his opinion by the following experiments : —
The marrow was removed from the thigh bone of a dog, and
mercury put in its place. At the end of five days, the dog died,
and the mercury was found strewed through the lungs. Each
globule was the centre of a small liepatized mass. (Cruv. liv.
xi.)
In another dog, a single globule of mercury was placed in the
medullary cavity of the femur. A month afterwards, it was found
in the lungs divided into many very small globules, each the
centre of a small abscess.
The observation of Cruveilhier, that injuries which involve bones
are those most frequently followed by scattered abscesses, includes,
CAUSES.
53
as a particular instance, the fact, long ago noticed, that injuries
of the head are often followed by abscesses of the liver.
From the researches of Mr. Arnott in this country, and of
MM. Dance and Cruveilhier in France, no doubt remains that
the abscesses in such cases result from suppurative inflammation
of a vein, either in the soft parts, or between the tables of the
skull.
Many false theories of the mode of formation of the abscesses
of the liver consequent on injuries of the head, have been main-
tained under the erroneous impression that abscesses exist in the
liver only. It was, however, long ago remarked by Morgagni,
that, in these cases, there are often abscesses in the lungs, heart,
spleen, and other organs, as well as in the liver. The abscesses
in the liver attracted more attention than those in the lungs, on
account, perhaps, of their larger size, and their being more con-
spicuous from the stronger contrast between the colour of pus and
the natural colour of the organ.
There is a close analogy between the secondary abscesses from
phlebitis, and secondary masses of cancer.
A cancer of the breast may be the source of cancerous tumors
in the lungs and liver, just as an inflamed vein in the arm may he
the source of abscesses in those parts.
The abscesses and the secondary cancerous tumors will be
scattered in the same manner, and immediately surrounded by
healthy pulmonary or hepatic tissue.
The lungs and the liver are the organs in which secondary can-
cerous tumors, as well as the abscesses from phlebitis, are most
frequent.
The cancerous tumors and the abscesses have in each organ
the same form and seat ; and in the lungs, both have a great
predilection for the surface.
These points of resemblance can hardly he explained, except on
the supposition that the germs of the two diseases, — cancer-cells
and pus-globules, — are disseminated in the same manner through
the veins.
It may be considered then established, that the abscesses
which form in the liver and other organs, after surgical operations
and injuries of the head or limbs, are owing to suppurative in-
flammation of a vein, and the consequent contamination of the
blood by pus. The globules of pus, mingled with the blood, are
54
SUPPURATIVE INFLAMMATION OF THE LIVER.
conveyed to the capillary vessels of the lungs, and, it would seem,
by becoming mechanically arrested there, excite each circum-
scribed inflammation and abscess. If any of the globules pass
through the capillaries of the lungs to the left side of the heart,
they are sent in the arterial current to other organs, and becom-
ing arrested in the capillaries of these organs, excite, as in the
lungs, inflammation of limited extent, rapidly passing on to
abscess.
These scattered abscesses are most commonly found after
operations or injuries, because suppurative inflammation of the
inner surface of a vein is most commonly caused by mechanical
injury of its coats; but they may obviously result from suppura-
tive phlebitis set up in any other way. I have met with two in-
stances in which scattered abscesses in various organs seemed to
result from a collection of pus that had formed, from some cause
which I could not discover, between the periosteum and hone of
the upper arm ; another instance, in which their source was pro-
bably a large tuberculous cavity in the lungs.
Perhaps, then, we are justified in concluding in all cases in
which we find collections of pus rapidly formed in different parts
of the body, that the immediate cause of these scattered inflamma-
tions is some irritating substance conveyed there by the blood ;
and in most of the cases where the abscesses in the lungs are
small and circumscribed, that this irritating substance is pus,
derived from inflammation of the inner surface of a vein.
In cases in which we cannot find the inflamed vein, the facts,
that the abscesses are scattered in the same way, and occupy the
very same anatomical seat as in those cases in which the source
of the pus is known — that this kind of dissemination and the
anatomical seat occupied are also the same as in the case of in-
jected mercury and secondary cancer, — are conclusive in showing
that the agent arrives by the blood, and almost conclusive that
this agent is a pus-globule.
The proportion of cases of this kind, in a given number of
cases of abscess of the liver, will, of course, vary with the fre-
quency of abscess of the liver from other causes.
In India, where other powerful causes of abscess of the liver
are in operation, the proportion will he small. In the cases
published by Annesley, there is not one that we can, from his de-
scription, place in this category.
CAUSES.
55
In the fifteen cases that fell under my own observation at the
Dreadnought, there is only one that clearly belongs to this head.
In this instance, abscess of the liver, with abscesses of the lungs
and collections of pus in various joints, resulted from phlebitis
caused by the operation of bleeding.
In the sixteen cases collected by Louis and Andral, in Paris,
where abscess of the liver from other causes is less frequent, there
are four which may be placed in this category; — one, in which
the abscesses were consequent on venesection ; (Louis, Obs. 2 ;)
another, in which they were consequent on childbirth ; (Louis,
Ohs. 1 ;) a third, (Andral, Obs. 23,) where with abscesses of the
liver, there was lobular pneumonia of the left lung, grey hepa-
tisation of the right, and pus between the vertebral column and
pharynx ; a fourth, (Andral, Obs. 26,) in which there was grey
hepatisation of the lower lobe of the left lung, and pus in the me-
diastinum.
As yet, I have alluded only to inflammation of those veins that
return their blood immediately to the vena cava, in which case the
pus must pass through the capillaries of the lungs before it can be
sent to other organs. In such cases, abscesses are sometimes
found in the lungs only, and are usually more numerous in them
than in other organs. But if one of the veins that go to form the
vena portae be inflamed, the pus will be carried to the liver first,
and abscesses will be found solely, or in greatest number, in that
organ. Cruveilhier found, that if mercury be injected into one of
the veins that feed the vena portae, it will all be stopped in its
course through the liver, and will cause circumscribed abscesses
there, just as it does in the lungs when injected into the crural
vein.
He injected mercury into one of the mesenteric veins of a dog.
At the end of twenty-four hours, the dog died, and the surface of
the liver was found sprinkled with small spots of a deep red
colour, which extended four or five lines into its substance. In
the centre of each of these red masses was a small globule of
mercury. (Cruv. liv. xi.)
In another instance, having met with a dog having an umbilical
omental hernia, he injected mercury into one of the small veins of
the omentum. The dog was killed about ten weeks after, and
56
SUPPURATIVE INFLAMMATION OF THE LIVER.
tlie liver found studded with a countless number of, wlmt Cruvcil-
hier calls, tubercles, in the centre of each of which was a globule
of mercury.
Some of these tubercles had two distinct layers : the outer, al-
buminous or tuberculous ; the inner, puxiform.
In these two experiments the different stages of suppurative
inflammation are seen. At first, there is a spot of a deep red
colour ; — this passes to suppuration and abscess ; and the matter
of this abscess, acting as a source of irritation, excites around it
inflammation of a different kind, which leads to effusion of albu-
men or fibrin, and thus forms a cyst for the matter.
The veins that feed the vena portae, are little exposed to acci-
dental injury, hut some of their branches are divided in operations
on the rectum and for strangulated hernia ; and, as might have
been anticipated, these operations are sometimes followed by
abscess of the liver.
Cruveilhier relates a case where abscesses of the liver were
immediately consequent on repeated attempts to return a pro-
lapsed rectum.
The patient, a man of sixty, had been subject to prolapsus
many years. The bowel protruded at the first effort to empty it,
but was usually returned ■without difficulty. When he sought
assistance on the last occasion, it had been down twenty-four
hours, and was replaced only after repeated and violent attempts,
which gave him much pain.
The same day, the expression of his countenance altered, and
his pulse became small and unequal. He soon fell into a state
of prostration, with a cold skin, vomiting, hiccough, stupor, but
without pain, and died on the fifth day.
A great number of small abscesses, some superficial, others
deep-seated, were found in the liver. The hepatic tissue for a
short distance round each of them was of a brown-slate colour and
softened. (Cruv. liv. xvi.)
Dance mentions a case in which abscesses formed rapidly in
the liver after an operation for cancer of the rectum, where cau-
terization was practised ; another, in which they were consequent
on a simple operation for fistula ; two others, in which they
followed the operation for strangulated hernia, where a portion of
CAUSES.
57
irreducible omentum suppurated externally. (Archiv. Geuerales,
t. xix. p. 172.)
There can be little doubt tlmt in all these cases, the abscesses
in the liver were the consequence of phlebitis caused by the
operations.
It is an important circumstance, and one to which I shall again
have to refer, that in none of the cases do Cruveilhier or Dance
speak of abscesses in other organs. It would seem that all the
pus furnished by the inflamed veins, was stopped in its passage
through the liver ; and that abscesses formed in the liver only.*
3rd. — The consideration of these cases leads us naturally to a
third cause — I believe by far the most frequent cause — of abscess
of the liver : namely, ulceration of the large intestine, or, more
generally, of the intestines, the stomach, the gall-bladder, or
ducts; parts, which return their hlood to the portal vein, to be
thence transmitted through the capillaries of the liver.
A connexion between abscess of the liver and dysentery has
long been noticed, but the two diseases are associated far more
frequently than has been generally imagined. Of the twenty-
nine cases recorded by Annesley, there are twenty-one, or nearly
three-fourths, in which there were ulcers, more or less extensive, in
the large intestine ; and two other cases, in which the large in-
testine was contracted or strictured, in consequence, no doubt, of
dysentery at some former period. It is not unlikely that in some
of the remaining cases ulceration of the intestines existed but was
not noticed.
Of the fifteen fatal cases which fell under my own observation
at the Dreadnought, the state of the intestines was not noticed in
two. In eight of the remaining thirteen cases, there were ulcers
in the large intestines, and in one other case, two ulcers in the
stomach ; so that, in nine of thirteen cases, or in nearly three-
fourths, there were ulcers in the large intestine or stomach. In
another of these cases, without ulceration of the stomach or intes-
tine, there was ulceration of the common gall-duct.
In the sixteen cases collected by Andral and Louis, who seem
not to have suspected any connexion between abscess of the
* In some instances, perhaps, the pus passes through, or the abscesses of
the liver cause inflammation of the hepatic vein, and thence disease of the
lung. In Ohs. 3, ofM. Louis, there were ulcerated intestines, abscess of the
liver, double pleuro-pneumonia.
58 SUPPURATIVE INFLAMMATION OF THE LIVER.
liver and ulcerated intestine, ulcers are noticed in the large intes-
tine and in the lower end of the ileum, in two cases ;* in the
lower end of the ileum only, in one case ;+ in the stomach, in four
cases in the gall-bladder, in one case.§
In one of the cases in which the stomach was ulcerated, the
ulcer communicated with the abscess, which was in the left lobe
of the liver. It is fair to conclude, as Andral does, that in this
case (Andral, Obs. 31) the ulcer was caused by the abscess
opening into the stomach. Excluding this case, there are still
seven cases out of fifteen, in which there was ulceration of some
part of the extensive mucous surface that returns its blood to the
portal vein.
The fact will appear still stronger, if we recollect, that in one
of these sixteen cases, the abscess in the liver was caused by a
blow ; that in four others, it seemed the consequence of phlebitis ;
and that in none of these five cases were there any ulcers in the
stomach, intestines, or gall-bladder. So that in seven out of
eleven cases, in winch the abscesses were not the consequence of
a blow or of general phlebitis, there was ulceration of the stomach,
the small or large intestines, or the gall-bladder.
It is impossible to suppose that this is a mere coincidence
of diseases having no relation to each other. In another of these
eleven cases (Andral, Obs. 32) the abscess of the liver was ob-
viously consequent on chronic disease of the stomach, and after
death, the lining membrane of the stomach was found in some
parts so softened as to resemble liquid mucus. In this last case,
and in the three cases in which there was an ulcer in the stomach,
the state of the large intestine is not noticed.
Here, again, I may adduce, as a further support to my position,
the analogy of cancer. Cancer of the stomach is frequently
followed by disseminated cancerous tumors in the liver, and in
no other organ. In a subsequent chapter I shall refer to nu-
merous instances of this kind from those storehouses of patho-
logy— the Clinique Medicale of Andral, and the Anatomie
Putholoc/ique of Cruveilbier. It would seem, that cancer-cells,
like pus- globules, usually, if not always, become arrested in the
liver, and do not pass through to become the germs of cancerous
tumors in other organs.
* Andral, Obs. 25 ; Louis, Obs. 3. I Andral, Obs. 24.
X Andral, Obs. 27, 30, and 31 ; Louis, Obs 4. § Louis, Obs. 5.
CAUSES.
59
The association of dysentery with abscess of the liver, is
noticed by most physicians who have treated of either of those
diseases.
Dr Cheyne, speaking of the dysentery of Ireland, says, that
in the majority of his dissections the liver was apparently sound ;
bnt that in two cases, he found abscesses in its substance. (Dub-
lin Hospital Reports, vol. iii.)
In two of the four cases of abscess of the liver, published by
Dr. Abercrombie, there were ulcers in the large intestine.* It is
remarkable that Dr. Abercrombie should have considered the asso-
ciation of the two diseases accidental. He says, “ Dysentery is
often accompanied by diseases of neighbouring organs, especially
the liver, in which are found in some cases abscesses, and in the
protracted cases chronic induration. These are to he regarded as
accidental combinations, though they may considerably modify
the symptoms.” (Diseases of the Stomach, &c., 2nd edition, p.
266.)
Annesley, much struck with the frequent association of the
two diseases, and impressed with the importance of establishing
their true relation, confesses his inability to do this. He sup-
poses that, in some cases, the abscess is consequent on the dysen-
tery ; that, in others, the dysentery is the mere consequence of
the disease of the liver ; while, in a third order of cases, the
disease of the liver and that of the large intestine are coeval, or
so nearly coeval, that it is almost impossible to decide which had
priority (Annesley, vol. ii. p. 199). And, indeed, in India, it
must he extremely difficult to discover the relation between the
two diseases, on account of the great prevalence of other disorders
of the liver that are not easily distinguished from abscess during
the life of the patient.
In the cases that fell under my own care in the Dreadnought,
I experienced the same difficulty, and generally found it im-
possible to tell, from the history of the case, which had priority —
the disease of the liver or the dysentery.
In some cases, however, it was impossible to resist the con-
clusion, that the abscess of the liver was not only consequent on
the dysentery, hut caused by it.
On the 12th of March, 1838, four men, Brown, Flctt, Crere,
and Davies, were brought into the Dreadnought, from the same
* Diseases of Stomach, &c. ; 2nd edition; cases 93, & 130.
60
SUPPURATIVE INFLAMMATION OF THE LIVER.
vessel, the Renown, in a dreadful state of dysentery. The
Renown had just come from Calcutta, and had lost many of her
crew from dysentery between Calcutta and the Cape. At the
Cape, having hut five men before the mast remaining, she shipped
seven fresh hands, among whom were Brown, Flett, Davies, and
Crere, at that time in perfect health. Some of the original crew
continued to suffer from dysentery after leaving the Cape, but
these new hands had good health until, between the western
islands and the channel, when they had gotinto cold weather, they
were attached, one after another, with dysentery of the most
severe kind. Two of these men died soon after their admission
to the Dreadnought, the others recovered sufficiently to leave the
hospital.
In the two fatal cases, I found the state of the large intestine
exactly the same. From the ileo-ccecal valve to the rectum, the
mucous membrane was almost entirely destroyed by sloughing.
In one of these cases, the liver contained three small abscesses,
not encysted, and evidently quite recent ; in the other, the liver,
as far as I could then judge, was perfectly healthy.
Now, the primary disease in the two cases was obviously the
same, produced by the same cause. And as disease of the fiver
was only found in one of them, we must infer that it was se-
condary, the consequence of the dysentery.
Among many cases of dysentery, there may he only one in
which abscesses form in the fiver, just as among many cases of
amputation or of injury of the head, there may be only one in
which abscesses form in the lungs and other organs.
In another case that fell under my care in the Dreadnought,
the patient had dysentery at the Isle of France. The violent
symptoms subsided after two months, and he continued his work
for four years. At the end of this time, while on his passage
home from the East, diarrhoea recurred, and he had, for the first
time, pain in the right side and shoulder. These symptoms had
lasted three months, when he was brought into the Dreadnought.
He died soon afterwards.
On examination, I found a superficial abscess on the convex
surface of the right lobe of the fiver. The mucous membrane of
the small intestine was quite healthy to within two inches of the
ileo ■ccecal valve. Immediately above that valve, were three ulcers,
(the largest about the breadth of half- a- crown,) in most part of
CAUSES.
Gl
which the muscular coat of the iutestine was laid bare. The
edges of these ulcers were not raised or ragged. In their imme-
diate vicinity were many other ulcers, about the size of small-pox
marks, which had not eaten through the mucous membrane.
The mucous membrane about these ulcers was not softened or
unusually vascular. In the coecurn, was a single ulcer, the size of
a crown piece, having the same appearance as the larger ulcers in
the small intestine. The mucous membrane in the whole ccecum
was much softened ; in the rest of the large intestine it was in all
respects healthy. The mesenteric glands in the neighbourhood of
the ccecum were enlarged and softened to a pulp of a pinkish
colour. There was no ulceration of the stomach or gall-bladder ;
no enlargement of the patches of Peyer, or of the solitary glands
of the small intestine.
The sequence of events in this case seemed to he, dysentery,
winch had left a few chronic ulcers in the ccecum and lower end
of the small intestine ; at the end of four years, recurrence of
dysenteric symptoms, inflammation and abscess of the liver. The
abscess of the liver clearly dated from the recurrence of the dy-
senteric symptoms, when the patient first felt pain referable to the
liver. An abscess so superficial could not have existed without
manifest symptoms.*
If the liver- disease had been the cause of the dysentery, it
would, in all probability, have caused more extensive ulceration.
Irritating bile might cause ulcers of the large intestine, and
scattered ulcers, but it could hardly affect so exclusively, such a
small portion of the gut.
I might adduce other instances, which I should perhaps weary
the reader by relating, in which there could he little doubt that
the abscesses in the liver were secondary to dysentery.
We are led, then, to the conclusion, admitted by Annesley, that
abscess of the liver is in some cases consequent on dysentery,
and caused by it.
The question now arises : — Is it not so caused in all the cases,
or in most of the cases, in which the two diseases are asso-
ciated ?
Annesley thought not, from the circumstance, that, in India,
* Compare this case with Obs. 25 of Andral, where suppurative inflam-
mation of the liver occurred in the course of chronic enteritis.
62
SUPPURATIVE INFLAMMATION OF THE LIVER.
the symptoms of liver-disease sometimes appear as soon as those
of dysentery ; iu other cases, even before them.
The circumstance, that the symptoms of liver-disease appear as
soon, or nearly as soon, as those of the dysentery, does not prove
that the former disease is uot dependent on the latter. In the
case above cited from Cruveilhier, in which abscesses in the
liver were caused by the rough handling of a prolapsed rectum,
the symptoms commenced almost immediately after the injury,
and at the end of five days, when the man died, the matter in the
abscesses was fully formed. After an amputation or injury, in-
flammation of a vein may occur, pass on to suppuration, and con-
taminate the system, in less than forty-eight hours. Supposing,
then, the suppurative inflammation of the liver to be excited in
the same way in dysentery, it might be expected, that its symp-
toms would, in some cases, appear almost as soon as those of the
primary complaint.
But, in India, it sometimes happens that the symptoms of liver-
disease precede those of dysentery. Tliis, also, is what might
have been expected.
In India, derangements of the liver, consisting in excessive,
and perhaps vitiated secretion of bile and inflammation of the
gall-ducts, are very common ; the consequence, it would seem,
of the heat of the climate and the free living in which the Eng-
lish in India indulge.
Adhesive inflammation of the liver, terminating in induration
and cirrhosis, is, also, very common there, as in this country,
from spirit- drinking. Now although neither of these disorders
may terminate in suppurative inflammation of the liver and
abscess, yet they present nearly the same symptoms, and may
he readily mistaken for it. If, then, a person with any such de-
rangement of the liver should he taken with dysentery, and have
abscess of the liver in consequence, it is very natural that the
dysentery should he ascribed to pre-existing suppurative inflam-
mation of the liver.'*
If the explanation I have offered he rejected, we are almost
driven to conclude, as Annesley does, that the dysentery in these
last cases is caused by the passage of irritating bile. Now, if
this were the case, we should expect to find the most evident
* Cases 71, 75, 77, of Annesley, are probably examples of this sequence
chronic disease of the liver, dysentery, abscess of the liver.
CAUSES.
63
marks of disease in the gall-ducts and the upper part of the
small intestine — parts, with which the irritating secretion came
first in contact; hut, instead of this, these parts are almost
always perfectly healthy in cases in which abscess of the liver i s
associated with the most destructive forms of dysentery. The
whole of the large intestine may be a complete slough, while the
gall-bladder and ducts and the small intestine almost down, or even
quite down, to the ileo-coecal valve, are perfectly healthy, and the
bile in the gall-bladder is of its natural consistence and colour.
Annesley, indeed, makes a distinction between what he calls
simple dysentery and hepatic dysentery ; and states that in simple
dysentery, or dysentery unconnected with liver disease, the in-
flammation of the large intestine generally stops abruptly at the
ileo-coecal valve, while in hepatic dysentery, the lower part of the
small intestine is often inflamed, as well as the large intestine.
He believes that in the latter cases the small intestines become
diseased from the irritating quality of the bile. Annesley is
right in stating that in dysentery connected with abscess of the
liver, the lower extremity of the ileum is often found diseased as
well as the large intestine. It was so in five of the fifteen fatal
cases of abscess of the liver I treated at the Dreadnought, but it
not unfrequendy presents just the same marks of disease in cases
of simple dysentery.
I have met with many cases of simple dysentery, in which the
ulceration of the bowel did not stop short at the ileo-coecal valve;
but extended twelve or eighteen inches up the small intestine.
Cruveilhier has given a plate in which this is very faithfully re-
presented ; and in three out of eight cases of simple dysentery,
in which Annesley has given an account of the dissections, (vol.
ii. Cases, 172, 173, 179,) the lower end of the ileum was in-
flamed as well as the large intestine.
The proper reading of these facts seems to me to be, tbat the
disease of the bowel in dysentery is, in some cases, strictly
limited to the large intestine, while in others, it creeps a little
way up the small intestine ; in some, it causes abscess of the
liver, in others, not.
In no cases, whether of simple or hepatic dysentery, is the
upper part of the small intestine ulcerated. The ulcers of the
small intestine, if any exist, are always near the ileo-coecal valve.
There can be no doubt that a copious flow of irritating bile
8
04 SUPPURATIVE INFLAMMATION OF THE LIVER.
may cause diarrhoea, and may prevent the ulcers of dysentery
from healing ; it may perhaps cause ulceration of the howel ; hut
it is very improbable that it causes the early and extensive ul-
ceration and gangrene of the large intestine in Asiatic dysentery,
which often destroys life in a few days, while the small intestine,
almost in its entire length, remains perfectly healthy.
The more probable explanation is that which I have before
given ; namely, that in these cases the patient had some derange-
ment of the functions of the liver, which was followed by dy-
sentery, and then by abscess ; and consequently, that in all the
cases, or most of the cases, in which abscess of the liver and dy-
sentery are associated, the former disease is the consequence of
the latter.
If irritating bile cause ulceration of the intestine, it may he
the remote cause of abscess of the liver, through the disorder it
first occasions in the intestine.
Admitting dysentery, or ulceration of the howel, to he a source
of abscess of the liver, it is obvious that the liver does not be-
come involved by spreading of the inflammation, hut by some
contamination of the portal blood.
This may he either by pus, formed by suppurative inflammation
of one of the small intestinal veins ; or by matter of other
land resulting from softening of the tissues ; or by the fetid
gaseous and liquid contents of the large intestine in dysentery,
which must he absorbed and conveyed immediately to the liver.
It seems probable, that contamination of the first kind usually
gives rise to small scattered abscesses ; of the last, to diffuse in-
flammation, and a larger, perhaps single, collection of pus. If
the morbid matter be such that it does not mix readily with the
blood— as globules of pus or mercury — it will cause small, cir-
cumscribed abscesses, the rest of the liver being healthy: If, on
the contrary, the morbid matter be readily diffusible in the blood,
all the blood will be vitiated, and diffuse inflammation result.
The admission of this explanation of the relation of abscess of
the liver to dysentery, would lead us to expect that abscess of the
liver might occasionally be consequent on ulceration of the
stomach, or gall-bladder, — parts, which, like the larger intestine,
return their blood to the portal vein, — and this is found to be the
case.
It has been already remarked that in the sixteen cases of
CAUSES.
G5
abscess of the liver recorded by Andral and Louis, there are three
in which the stomach was found ulcerated, without any ulceration
being noticed in the intestines or gall-bladder.
In the first of these cases, (Andral, Obs. 27,) the patient, a
man about forty-one years of age, died of ulcerated cancer of the
stomach. The liver was enlarged, and contained scattered through
it, a great number of small, firm, red masses, the result, it was
supposed, of partial inflammations; but which were more probably
cancerous. In the centre of one of these red masses was an
abscess the size of a hazel-nut.
In another of these cases, (Andral, Obs. 30,) the patient, a
man about sixty, had presented for a considerable time the symp-
toms of chronic gastritis— loss of appetite, vomiting, sour eructa-
tions, and a sense of weight at the epigastrium. He became
sallow, and lost strength and flesh. He was somewhat benefited
by milk diet and soothing measures, wlieu, all at once, his pulse
became frequent, he fell into a state of prostration, with a
brown tongue, and died at the end of some days.
The coats of the stomach, for the breadth of five or six fingers
in front of the pylorus, were much thickened ; the mucous mem-
brane was ulcerated ; and in place of the underlying coats, there
was a uniform gristly substance of a dead white colour.
The stomach was united to the liver by bands of false membrane.
The liver was of its usual size. In the left lobe was a cavity,
the size of a small apple, filled with pus, and lined by a thick and
tough membrane. The hepatic tissue surrounding the abscess
was in a state of gangrene.
In this case, the abscess of the liver could not have caused
the ulcer of the stomach ; but the ulcer may fairly be presumed
to have been the cause of the abscess. The abscess had existed
for some time. The state of prostration marked the occurrence
of gangrene about it.
In the third case, (Louis, Obs. 4,) the patient, a man of fifty,
had had for four years disordered digestion, irregular appe-
tite, occasional slight pains in the left hypochondrium, now and
then nausea and purging, and frequent alternations of leanness
and moderate embonpoint. Seventeen days before his admission
to the hospital, he became much worse than usual, and a set of
new symptoms appeared — heat of skin, jaundice, complete loss of
appetite, severe pain at the epigastrium, and in the left hypo-
F
66
SUPPURATIVE INFLAMMATION OF THE LIVER.
chondrium, and slight oppression. These symptoms continued,
and for the last eight days he had, besides, purging and some
nausea. He died a fortnight after he entered the Hospital.
The liver was somewhat larger than natural, and contained a
great number of small abscesses lined by a thin and soft false
membrane. Its tissue was softened throughout.
The gall-bladder was small, and obliterated at its neck. The
cystic duct contained a gall-stone. The coats of the gall-bladder
and cystic duct, were much indurated and thickened. The hepatic
duct and the ductus communis, perfectly healthy.
In the portion of the stomach intermediate to the splenic and
pyloric extremities, the mucous membrane was thicker than
natural, and presented many deep ulcers, three or four lines in
breadth.
Here, as in the former cases, we cannot ascribe the ulcers in
the stomach to the disease of the liver, but the abscesses in the
liver may he fairly attributed to the disease of the stomach.
There was likewise, indeed, disease of the gall-bladder and cystic
duct ; hut this, which was of long standing, presented no marks of
recent activity, whereas it was obvious that the abscesses in the
liver were of recent date.
In another case by Andral (Andral, Obs. 32,) to which I have
already alluded, an abscess of the liver seemed consequent on
softening of the mucous membrane of the stomach. The patient,
a man aged 51, had symptoms of chronic gastritis for eighteen
months, when he became jaundiced, and began to have a constant
and troublesome pain in the right shoulder. Some time after the
accession of these last symptoms — Andral does not say how long — ■
he was seized suddenly with symptoms of peritonitis, and died at
the end of three days.
In the liver was an abscess, not encysted, which had opened into
the cavity of the peritoneum on the under surface of the liver near
the gall-bladder. The gall-bladder and the ducts were healthy.
In the splenic extremity of the stomach, the mucous mem-
brane was much softened ; in some parts so much as to re-
semble liquid mucus on the subjacent tissue. In the pyloric
extremity, on the contrary, the mucous membrane was hypertro-
phied.
Here, symptoms of disease of the stomach had lasted eighteen
months before the patient had any symptoms of disease of the
CAUSES.
07
liver. The circumstance that the abscess was not encysted goes to
prove that it was of recent date.
In the Provincial Medical Journal for December 3, 1842, the
case of a man is related who died at the age of 48, with ulcerated
cancer of the stomach. The liver contained seven or eight
abscesses.
In the Medical Gazette for Nov. 24, 1843, there are two cases
by Dr. Seymour, where a simple ulcer of the stomach had caused
circumscribed abscess of the peritoneum. The patients were
young maid-servants. In one, there was a large abscess in the
upper part of the right lobe of the liver, which during life had
burst through the diaphragm into the lung.
Ulceration of the gall-bladder or ducts, seems just as efficient
as ulceration of the stomach, in causing abscess of the liver.
I would cite as a probable example of this, the last case
given by M. Louis (Louis, Obs. 5). The liver contained from
thirty to forty abscesses, from the size of a pea to that of a filbert,
not encysted, and evidently of recent formation. There was no
ulceration of the stomach or intestines, but in the gall-bladder,
which contained some small calculi, there were six round ulcers ;
three superficial, and three deep. The mucous membrane of the
gall-bladder was three times as thick as it should be.
A case very similar to this is given by Dr. Bright in the 1st
volume of Guy’s Hospital Reports (p. 030) : gall-stones, ulcera-
tion of the gall-bladder, numerous abscesses in the liver.
With these cases may be classed one of the cases I had to treat
at the Dreadnought.
The patient, aged 33, was brought into the Hospital on the
2nd of December, immediately on his return from Quebec. At
Quebec he had ague, and this was succeeded, three weeks before
bis admission, by jaundice and pain below tbe ensiform cartilage.
The jaundice continued, but he had gained strength, when, on the
2Gth of January, just eight weeks after he was brought into the
hospital, he -was suddenly seized with symptoms of peritonitis,
which carried him off in four days.
On the convex surface of the right lobe of tbe liver was a
large irregular abscess, lined by a buff- coloured, and moderately
firm, false membrane.
The gall-bladder was firmly adherent to the duodenum, audits
F 2
G8
SUPPURATIVE INFLAMMATION OF THE LIVER.
coats were thickened. Its cavity, which was no larger than a hazel-
nut, was filled hy a yellow, friable gall-stone, having a firm dark-
green nucleus. The cystic duct was much dilated, and contained
a similar gall-stone, the size of a small bean. The common duct
was also much dilated, and communicated with the duodenum by
an ulcerated opening rather larger than a split pea, about two or
three lines from the natural termination of the duct. The hepatic
ducts were very large, and were readily traced a long way into the
liver. There was no ulceration of the stomach, or of the intestines,
with the exception of this ulcerated opening in the duodenum ;
which, as well as the dilatation of the ducts behind and the
jaundice, was caused, no doubt, by a gall-stone, which had stuck
for some time in the common duct, and then passed, hy ulcera-
tion, into the bowel.
To these cases may be added a case for which I am indebted
to Mr. Bowman, and which is given at length in another
chapter. A large hydatid cyst opened into the gall-bladder. In
a remote part of the liver was a small abscess. There was no
ulceration of the stomach or intestines.
In the twenty-nine cases related hy Annesley, to which I have
so often referred, there are, as I have already remarked, twenty-
three, in which there were ulcers, or the scars of ulcers, in the
large intestine. In four only of these twenty-three cases, does
Annesley notice any morbid change in the gall-bladder or ducts ;
while he remarks it in three of the remaining six cases.
In one of these three cases (case 81), the gall-bladder was very
small, and seemed to be divided hy a stricture in the centre.
In another (case 93), the common duct was much compressed
and obstructed by enlargement and hardening of the pancreas,
which completely enveloped it. On laying open the cystic duct,
the mouth of the gall-bladder was found much constricted hy a
cartilaginous hand. The intestines, small and large, were quite
sound.
In the third case (case 120), the gall-bladder completely
adhered to the wall of the abscess, and communicated with it.
The ducts were impervious, being involved in the adhesive
inflammation of the parts that hounded the abscess ; and the
bile secreted by the liver was either retained in the abscess, or
discharged hy the wound. (The abscess had been opened.)
I here was no other appearance of disease in any of the viscera.
CAUSES.
69
Abercrombie, in bis work on diseases of the Stomach, Ac., has
given four fatal cases of abscess of the liver. In two of these
cases, to which I have already referred (cases 93 and 130), there
were numerous deep ulcers in the large intestine, but no mention
is made of disease of the gall-bladder or ducts, or of gall-stones ;
in the other two cases (cases 128 and 129), there were large or
numerous gall-stones in the hepatic or common ducts, or in the
gall-bladder, but there was no disease of the intestinal canal. In
the latter cases, the gall-stones, probably by causing ulceration of
the ducts, seem to have taken the place of the ulcerated intestine,
in setting up suppurative inflammation of the liver.
The ducts, the gall-bladder, and tlie capsule of the liver, are
nourished by the hepatic artery, and blood flows, not from the
portal vein to them, but from them to the portal vein. This
circumstance explains how ulceration of the gall-bladder, like
ulceration of the stomach or intestines, may cause abscess of the
liver; and it also explains the fact, noticed by many physicians
who have written on abscess of the liver, that in this disease the
gall-bladder, the large ducts, and the capsule, are seldom in-
volved. The suppurative inflammation is confined to those parts
of the liver that receive blood from tbe portal vein. The frequent
absence of every trace of inflammation of the capsule in cases of
abscess of the liver has been expressly noticed by Annesley and
by Dr. Stokes, as very important in reference to treatment.
Having collected instances of abscess of the liver apparently
originating in a vitiated state of the blood brought from the
mucous surfaces that feed the portal vein, we require, to complete
our catalogue of abscesses of tbe liver produced by contamination
of the portal blood, other instances in which the contaminating
matter is brought by the splenic vein. My friend, Mr. Busk, has
furnished me with notes of the appearances after death in a case
which seems to have been of this kind.
The liver contained a great number of abscesses, about the size
of walnuts, containing thick white pus. The intermediate hepatic
substance did not seem inflamed. It was pale, firm, and of natural
appearance.
The splenic vein was much dilated. The branches by which
it arises from tbe spleen, and all that part of it which runs on the
pancreas, were inflamed, and contained a puriform fluid, aud an
rrre^rlar deposit of lymph.
70
SUPPURATIVE INFLAMMATION OF THE LIVER.
A large portion of the spleen was pale, and partially separated
as a gangrenous mass from the rest of the organ, which was of a
deep red colour, and very soft.
There were no ulcers in the intestines ; no abscesses anywhere
hut in the liver.
The most probable supposition is, that the disease in this case
originated in the spleen, that the splenic vein subsequently be-
came inflamed, and that the disseminated abscesses in the liver
were caused by the noxious matter brought to it by the vein. If
this matter were pus, we have another instance of pus brought in
large quantity to the portal vein, being all arrested in its passage
through the liver.
A circumstance strongly confirmatory of the view I have taken
of the different sources of abscess of the liver in the cases that
have been adduced, is, that not more than one of these probable
sources existed in the same subject. Where the abscess could he
traced to a blow or to suppurative inflammation of some vein that
returns its blood immediately to the vena cava, there were no
ulcers in the stomach, intestines, gall-bladder or ducts. When
ulcers were found in the intestines, by which the occurrence of
abscess in the liver could he explained, there were no ulcers in
the stomach, or gall-bladder. When the stomach was ulcerated,
there were no ulcers in the intestines or in the passages of the
bile. When there were ulcers in the gall-bladder or ducts, there
were none in any part of the intestinal canal.
It is not, perhaps, every form of ulceration of the stomach and
intestines, that gives rise to abscess of the liver. I have never
seen abscess of the liver noticed in conjunction with ulcerated
intestine in typhoid fever. This fact is very striking when we
consider how prevalent and fatal typhoid fever is ; how generally it
is attended with extensive ulceration of the bowels ; and how atten-
tively all the morbid appearances in this disease have been
observed and recorded, of late years, in this country and in
France.
Abscess of the liver is not noticed in any of the cases (ten in
number) of ulceration of the duodenum after burns, given by Mr.
Curling in his paper in the Med. Chir. Trans, for 1842. It is
very rare in conjunction with ulceration of the intestine, in
phthisis. In two of the cases given by Andral in which abscess
of the liver was associated with ulceration of the intestines, there
CAUSES.
71
were tubercles in the lungs, and the ulcers were probably of
tuberculous origin. But these form an insignificant proportion in
the immense number of fatal cases of phthisis with ulcerated in-
testines, in which the morbid appearances have been observed and
recorded. It is also rarely consequent on simple ulcer of the
stomach. The only instance I have met with, of this sort, is the
case already cited from Dr. Seymour.
Abscess of the liver seems to occur chiefly iu conjunction with
the sloughing ulceration in acute dysentery ; and with chronic
ulcers attended with thickening and induration of the submucous
areolar tissue. In the latter cases, the inflammation of the liver
occurs on some exacerbation of the gastric, or dysenteric
symptoms.
The causes that have here been assigned for abscess of tbe liver,
will, I believe, be found to apply to a great majority of cases — at
least, of the cases that are met with in this country. There will
remain, then, if I am right in my conclusions, but few cases that
require us to admit the agency of other causes.
Yet various other conditions have been very confidently as-
signed as causes of suppurative hepatitis.
Among these may be mentioned —
1st. Inflammation of the duodenum. Great importance was
attached to this presumed cause by Broussais and his followers.
Broussais, having remarked that the lymphatic glands in the
vicinity of ulcerated mucous membranes are often enlarged and
inflamed, and dwelling on the known sympathy between some
secreting glands — the lachrymal, the salivary — and the adjacent
mucous membranes, was led to generalize, and to assign inflamma-
tion of the duodenum as the most frequent cause, indeed as almost
the only cause, of inflammation of the liver. This opinion is not
borne out by facts. In most of the cases collected by Andral and
Louis, and in those observed by myself, the condition of the duode-
num was noticed ; and in hardly one did it present any trace of
disease. Ulceration* or organic disease of the duodenum may, no
doubt, cause abscess of the liver, like similar disease of other
parts which transmit their blood to the portal vein, but such dis-
ease is very rare in the duodenum.
2nd. — Another cause assigned for hepatitis, is spirit-drink-
ing. But this produces adhesive inflammation and induration
of the liver, not suppurative inflammation and abscess. Not-
72 SUPPURATIVE INFLAMMATION OF THE LIVER.
withstanding the great prevalence of the habit of gin-drinking
among the lower orders in this metropolis, years often pass away
without a single case of abscess of the liver being admitted into a
large London hospital. Not one has been received into King’s Col-
lege Hospital since its establishment — a space now of five years.
3rd. — A third cause confidently assigned by Annesley and many
other writers, is congestion of the liver. But this, assuredly, —
that is, mechanical, congestion, produced by impediment to the
flow of blood through the lungs or heart, — never produces sup-
purative inflammation. Abscesses of the liver are never met with
as a consequence of the congestion caused by the organic dis-
eases of the heart so common in our hospitals ; and in not one
of the cases recorded by Louis, or Andral, or Annesley, could
the abscesses be attributed to this condition. Of the other
kinds of congestion, and the points in which they differ from
states to which the term inflammation may properly be applied,
we know but little — and their influence in causing abscess of the
liver, will be comprehended in that of heat of climate, malaria,
and the other circumstances by which such states of congestion
are produced.
4th. — In India, great influence is attributed to the heat of the
climate in causing inflammation and abscess of the liver. A hot
climate, no doubt, deranges the functions of the liver, and causes
increased secretion of bile, which often is irritating in quality,
and produces inflammation of the gall-ducts and intestines, — and
in this indirect way, it may cause suppurative inflammation of
the substance of the liver. It may, perhaps, also, lead directly,
and without such intervention, to suppurative inflammation and
abscess ; but I feel persuaded that it does so far less frequently
than is generally imagined, and that the notion originated from
the prevalence of dysentery, which we have seen to be a frequent
cause of abscess, in many tropical climates. The heat of our
own summers, or of those of France, never brings on abscess of the
liver, which is very rare in the civil hospitals of London and
Paris. Sailors employed in the trade to the west coast of Africa
are exposed to heat, perhaps as great as those in the trade to
India, and suffer much more in health, but they are not equally
liable to abscess of the liver, or to dysentery.
Men employed in japanning, and other processes in the arts,
are often exposed to heat much greater than that of India, and
8
CAUSES.
73
their health suffers in consequence, yet we never find them coming1
into our hospitals with abscess of the liver.
5th. — Another cause brought forward to explain the frequency
of abscess of the liver in India, is remittent or intermittent
fever, or, mere correctly, the malaria that produces these
fevers. It seems established, that in some of these fevers, the
liver, like the spleen, becomes congested, and much enlarged in
consequence; and in yellow fever and the severe forms of re-
mittent fever, it is much and permanently damaged in its secret-
ing element. Yet it may be doubted whether suppurative
inflammation of the liver takes place in these cases without
ulceration of the stomach, or gall-bladder, or intestines, which
so often occurs in some climates in the course of the severe
forms of marsh-fever. During the time I was visiting physician
to the Dreadnought, I had continually to treat men in the most
deplorable state from fever caught on the west coast of Africa ,
but none of these men had abscess of the liver.
Louis, in his elaborate account of the yellow fever, which he
was sent by the French Government to observe, at Gibraltar, in
1823, says he constantly found the liver of a pale slate colour
from anemia, but without any marks of inflammation.
Annesley, indeed, notices abscesses in the liver, among the
morbid appearances of the remittent fever of India, but he also
notices ulceration of the intestine (Annesley, vol. ii. p. 45G).
Sir G. Blane, in his account of the Walcheren fever, remarks,
that the liver was occasionally the seat of abscess ; but here, as
in India, the fever was associated with dysentery. It is probable
that in both cases the abscesses occasionally found in the liver
were the consequence of the dysentery, and not the immediate
effects of the fever.
It may be, however, that in some parts of India, a peculiar
malaria, favoured perhaps by the heat of the climate, produces
abscess of the fiver independently of ulceration of any part of
the mucous surface that returns its blood to the portal vein.
We know that marsh-fevers differ very much in type, and
damage different organs in different seasons and climates ; and
even according to different degrees of concentration, merely, of
the poison by which they are produced. The question, once
asked, will soon be answered by men practising in India, who, in
74
SUPPURATIVE INFLAMMATION OF THE LIVER.
general, show the most praiseworthy zeal in collecting facts and
adding to our knowledge of all subjects connected with medicine.
Having considered the causes of suppurative inflammation of
the substance of the liver, we may proceed to the changes of
structure to which it leads.
The earliest perceptible changes in the appearance and texture
of the liver from suppurative inflammation involving its sub-
stance, are uniform redness and softening. These were the
earliest changes observed by Cruveilhier in his experiments of
injecting mercury into the mesenteric veins of dogs. When the
dogs died before sufficient time had elapsed for the formation of
pus, the mercury was found strewed through the liver, and the
hepatic tissue around each globule of a deep red colour, and
softened. In the human subject, in most cases of abscess of the
liver, when speedily fatal, the hepatic tissue about the abscess is
of a bright red and softened.
This preliminary stage, is, however, of very short duration.
The inflammation soon passes, in some cases i'n a few days only,
to suppuration and abscess. Dr. Stokes has noticed a stage, be-
tween red softening and abscess, in which the pus is disseminated
through the lobules of the liver, the form of which can still he
distinguished, and the inflamed substance is yellowish, and of
course still very soft.
I have never found this change in the liver without abscess,
nor does Dr. Stokes seem to have done so, hut in several instances
I have observed it extending a distance of two or three lines about
a recently formed abscess.
This state of yellow softening, or purulent infiltration, is, there-
fore, very transitory ; and we may, consequently, consider red
softening and abscess, as the anatomical characters of suppurative
inflammation of the substance of the liver.
The inflammation we are considering, commences in the lobular
substance of the liver, and is often confined to it; the capsule of
the liver, tne trunks of the vessels and of the ducts, being per-
fectly healthy. But if the inflamed part reach the surface of
the liver, adhesive inflammation is generally set up in the portion
of the capsule immediately above it, and coagulable lymph is
poured out, which causes permanent adhesion between that portion
CHANGES OF STRUCTURE.
75
of the liver and the parts with which it is in contact. This adhe-
sive inflammation is usually of small extent, being confined to the
portion of the capsule immediately above the abscess. It some-
times happens, too, when the portion of liver inflamed reaches a
trunk of the hepatic vein, that inflammation is set up within the
vein. In two instances in which abscesses had formed in the
liver after amputation of the leg, I found one or two branches of
the hepatic vein blocked up by soft fibrine ; and in each I ascer-
tained that an abscess reached the vein where it ceased to be ob-
structed by the fibrine. Backwards from this point, all the
twigs were blocked up that went to form the obstructed branch.
It would seem that the abscess, reaching the thin coat of the
vein, had set up inflammation within it, — just as it sets up
inflammation of the capsule at parts where it reaches the surface
— and that the vein being blocked up at that point by tbe effused
fibrine, all the twigs that went to form it, became obstructed in
consequence.
I have never found a branch of the portal vein inflamed in
such cases, but Dr. James Russel, of Birmingham, has sent me
notes of a very interesting case in which abscesses formed in the
liver and other parts, after amputation of the leg, and in which
he found lymph and pus in a branch of the portal vein contigu-
ous with one of the abscesses.
The branches of the hepatic vein are perhaps more apt to
become inflamed secondarily, in this way, than those of the
portal vein, from their coats being thinner, and from their not
being surrounded, like the branches of the portal vein, by areolar
tissue.
Abscesses of the liver sometimes attain an extraordinary
size. In one instance, I estimated the quantity of matter in an
abscess of the liver, at two quarts. A case is related by An-
nesley, in which an abscess in the liver contained ninety ounces
of matter ; and Dr. Inman, of Liverpool, has sent me an
account of one still more extraordinary, that fell under his own
observation, in which the quantity of matter was found by
measurement to be thirteen pints.
The matter in an hepatic abscess is usually white or yellowish ;
and is free from odour, unless when is close proximity to the
lung, where it sometimes becomes decomposed and fetid, from the
admission of air.
76
SUPPURATIVE INFLAMMATION OF THE LIVER.
Many of the old writers describe the pus of abscess of the liver
as being red or claret-coloured, but this is incorrect. In all the
abscesses of the liver that I have examined, tlie pus was white
or yellowish, just like that of a phlegmon. The error of those
who have described it as being reddish, resulted, perhaps, from
their having met with a case in which the abscess opened into
the lung, and in which the pus, in its passage through the lung,
became mixed with blood and broken down pulmonary tissue.
They described the matter expectorated, and not the matter con-
tained in the abscess. It is not very uncommon for an abscess of
the liver to open into the lung. Several instances of the kind
have fallen under my own notice, and in all of them the matter
expectorated was a dirty-red, or brownish, pus. The reddish colour
was acquired in its passage through the lung. The matter in
the abscess was yellowish or white.
Kokitansky states, that in old abscesses of the liver, there is
always an appreciable quantity of bile mixed with the pus. I did
not remark this in any of the dissections I made at the Dread-
nought; perhaps, from my attention not being directed to it.
In cases that have proved speedily fatal, the abscess is bounded
simply by red and softened hepatic tissue ; but in others, it is lined
by a false membrane or cyst. The structure of this cyst varies
very much in different cases, — depending in some degree, perhaps,
on the general condition of the patient ; but chiefly, on the date of
the abscess, and on its size. In small abscesses, and in abscesses
recently formed, the pus is surrounded by a layer of albuminous
matter, a line or two in thickness, resembling concrete pus, and
beyond this the hepatic tissue has its natural texture ; while in
old abscesses of large size the cavity is hounded by a dense grey
substance, like cartilage, three or four lines in thickness ; and the
hepatic tissue for a line or two even beyond this is pale and con-
densed, obviously in effect of pressure.
The following seems to be the mode in which these cysts are
produced. At first, the pus becomes circumscribed by a layer of
concrete albuminous matter. The abscess then acts as a foreign
body, causing pressure on the surrounding parts, and an inflam-
matory action which leads to the effusion of fibrine. The fibrine,
becoming organized, forms the cartilaginous-like layer described.
M' lion an abscess in the liver has become thus isolated by a
firm cyst, it may, especially if it be of small size, remain a long
CHANGES OF STRUCTURE.
77
time without further change ; but in most cases, after being, per-
haps, some time stationary, it grows larger, apparently through
secretion of fresh matter from the inner surface of the now
organised cyst. By the pressure exerted on it by the distcndiug
force, the cyst may become ulcerated, and in this way, as
well as by mere distension, tbe abscess may grow larger.
It would seem that, by the process of ulceration, a gall-duct
imbedded in the cyst, or lying on it, may be opened, and a
small quantity of bile become mixed with the pus. Rokitansky
thus accounts for the bile which he constantly found mixed with
the pus in old abscesses of the liver. He says, the large gall-
ducts about the abscess break down by the spreading of the sup-
puration, and open obliquely into the cavity on the distal side,
but only exceptionally, and in very large abscesses, on the side
towards the intestine.
When an abscess of the liver in its first formation, or by its
subsequent growth, reaches the surface of the liver, it may have
various issues. The abscess may burst into the cavity of the
peritoneum, causing inflammation of that membrane, which
proves speedily fatal. But this seldom happens. In a great
majority of instances, when the matter gets near the surface of
the liver, adhesive inflammation is set up in the portion of peri-
toneum immediately above it, and lymph is poured out, which
glues the liver to adjacent organs — to the abdominal parietes, the
diaphragm, the stomach, the duodenum, the colon, according to
the seat of the abscess, — and the matter is discharged, not into
the cavity of the peritoneum, but outwards, or into the lung or
pleura, or the different portions of the intestinal canal just
specified.
Livers containing abscesses are found of all shades of colour
that can be produced by different degrees of congestion, and
by differences in the quantity and colour of the biliary matter
retained in the cells ; but they are seldom indurated from inter-
stitial deposit of fibrine. The inflammation which terminates
in abscess, and that which leads to effusion of fibrine and in-
duration, or cirrhosis, are not different in degree merely, but in
kind also. Abscesses are never found in the hob-nail livers of
the gin-drinking population of our large towns ; and it happens
seldom, and then, I believe, only by coincidence, that there is
much induration of the liver in persons who return from India
with abscess of this organ.
78
SUPPURATIVE INFLAMMATION OF THE LIVER.
We may now consider the symptoms of suppurative inflamma-
tion of the liver.
In most works on medicine, these have been described as being
much more uniform than they really are. A picturesque group is
sketched, which it seems very easy to identify ; hut in actual
practice, it is far otherwise. The physicians who have had most
experience in this disease, confess their inability, in many cases,
to distinguish it from other diseases of the liver ; and in some,
even to pronounce that the liver is the seat of disease at all.
Here, as in the diseases of other internal organs, our diagnosis
will be much aided by knowledge of the circumstances under
which the disease arises. This knowledge will make us observant
of symptoms which would otherwise escape our notice, and will
enable us to interpret them rightly.
The symptoms are most in accordance with the descriptions
usually given, when the inflammation is caused by a blow, or
some direct injury from without. The injury is usually done
to the convex surface of the liver, and the local symptoms
are well marked. There is pain and tenderness in the region of
the liver, and a sense of fulness and resistance under the false
ribs, from increased size of the organ. The liver becomes en-
larged, and if the abdomen be flaccid, and the intestines empty,
its edge can he felt some inches below its natural limit. The se-
cretion of bile may he suppressed, or deficient, and the patient
jaundiced.
In addition to these symptoms, which may he called special,
from their pointing to the liver as the seat of disease, there soon
appear, as in simple inflammation of other organs, the general
symptoms of inflammatory fever : the pulse is frequent and full ;
the skin hot ; the tongue furred aud yellowish ; appetite is alto-
gether absent or much diminished. The patient is thirsty, and
there is occasionally vomiting of bilious matter, while the urine
is scanty, high coloured, and deposits a red sediment.
These general symptoms, together with the special symptoms —
pain and tension in the region of the liver, and jaundice — occur-
ring after an injury to the side, are perhaps, in the absence of
evidence of disease of the lung or pleura, sufficient to characterise
suppurative inflammation of the liver.
But, as before remarked, the liver is so well shielded by the
ribs, that the disease is seldom caused in this way. It occurs
SYMPTOMS.
79
much more frequently after injuries clone to other parts of the body,
and after surgical operations, from suppurative inflammation of
some vein, and the consequent contamination of the blood by pus.
In such cases, the general symptoms do not aid us in detecting
it. There is already high fever, which rapidly assumes a typhoid
character — the consequence of the contamination of the whole
mass of blood, and of the various local inflammations to which
this gives rise.
We can only infer that abscesses are forming in the liver by
the occurrence of special symptoms — pain in the region of the
liver and jaundice — in the midst of the general disorder. But
these special symptoms do not exist in all cases. There may be
no jaundice; and pain, even, may be wanting, or the typhoid state
into which the patient falls may prevent his. distinctly perceiving
or expressing it. In such cases, the abscesses in the liver can be
discovered only after the death of the patient.
In the same way, when inflammation of the liver occurs during
the acute stage of dysentery, or on a recurrence of acute symp-
toms in chronic dysentery, the general symptoms do not aid us in
discovering it, because they are fairly attributable to the primary
disease. The diagnosis must be founded on local symptoms
chiefly — pain and tenderness referable to the liver, tension in
the right hypochondrium, and jaundice. Our knowledge of the
connexion between the two diseases enables us to attach due im-
portance to these symptoms and ascribe them to their actual
cause. Pain and tenderness in the region of the liver, slight in-
crease in its volume, and jaundice, which, in other circumstances,
might excite little alarm, and be attributed to their most frequent
cause, — inflammation and obstruction of the gall-ducts, — when
they occur in the course of dysentery, will lead us to dread sup-
purative inflammation and abscess.
But these special symptoms are far indeed from being all pre-
sent in every case ; and in some cases they are entirely wanting.
On the 2nd of October, 1830, a Lascar, 02 years of age, was
admitted into the Dreadnought, with general emphysema and
catarrh. He complained only of weakness, but sweated at night,
and had hectic fever, which led to the suspicion that he had
miliary tubercles. ITe grew weaker, and died of the catarrh, on
the 12th of November. While in the hospital, he made no com-
plaint of pain or tenderness in the right hypochondrium, had no
80
SUPPURATIVE INFLAMMATION OF THE LIVER.
vomiting, no diarrhoea, no jaundice, — not a symptom to lead me
to suspect that his liver was diseased. On examination, an abscess,
containing more than a pint of matter, was found in the substance of
the liver. The abscess was hounded by a moderately firm cyst, and
the hepatic tissue for a line or two beyond this was pale and con-
densed. The rest of the liver was healthy, and the capsule presented
no marks of having been inflamed. The stomach and small in-
testines were healthy. In the large intestine, there were numerous
scars, traces of former dysentery, but no actual ulcers. The lungs
were extremely emphysematous, and the bronchial tubes choked
by mucus. There were no other marks of disease.
My friend and former pupil, Dr. Inman, of Liverpool, has sent
me notes of an interesting case, in which abscesses of the fiver
occurred, in consequence it would seem of dysentery, without any
symptom immediately referable to the fiver. The patient, a
woman 45 years of age, was admitted into theLiverpool Infirmary,
on the 21st of June, 1843, in a state of extreme weakness, from
bad living and from constant diarrhoea, which had then lasted
nine or ten weeks. The diarrhoea came on without urgent symp-
toms, and was unattended by griping or tenesmus. The stoctls
were occasionally tinged with blood. The belly was drawn in, and
not tender on pressure. She died on the 12th of July. There
was extensive ulceration of the large intestine from the ile'o-
coecal valve to the rectum. The stomach, the small intestines,
the kidneys, and the spleen, were healthy. The fiver was larger
than natural, and near the lower surface of the right lobe, were
three abscesses containing, in all, about twenty ounces of pure
yellow pus. The abscesses were not encysted, and their walls
were rough and jagged. There were no marks of inflammation
of the capsule of the fiver. The lungs were cedematous ; other-
wise healthy. In the account he sent me, Dr. Inman observes,
“ No pain in the side or shoulder had been noticed, no vomiting,
nor any other symptom that led to the suspicion that there were
abscesses in the fiver. The abscesses were discovered by acci-
dent, in the examination of the body.”
Andral, Abercrombie, and indeed all writers who have pub-
lished a series of cases of suppurative inflammation of the fiver,
have noticed the same fact, — that, occasionally, in this disease, the
patient has no symptoms immediately referable to the fiver.
Anncsley says, “ The supervention of abscess of the fiver ”
SYMPTOMS.
81
(in dysentery) “ is often not manifested by symptoms of a de-
cided nature.” “ The formation of matter may commence and
terminate without the appearance of any of those signs on which
the inexperienced are taught to rely.” In another place, he says,
“When the disorders of both viscera are nearly coeval, the inex-
perienced observer may not detect the presence of biliary de-
rangement, until the disease is hastening to a fatal termination,
and unequivocal signs of abscess are present. In cases of this
description, the violence of the dysenteric symptoms absorbs the
whole attention of both patient and practitioner, and the compli-
cation is overlooked.”
The presence or absence of the symptoms directly referrible to
the liver depends chiefly on the situation, and extent, of the part
of the liver inflamed. These symptoms are, as before remarked,
fulness of the right hypochondrium, from enlargement of the
liver; pain or tenderness ; and jaundice.
The degree of enlargement must evidently depend in some
measure on the extent of the part inflamed. If only a small
portion of the liver be inflamed, the inflammation, though at-
tended with considerable distension of vessels, may run through
all its stages without producing any enlargement of the organ
discoverable by touch. But in this kind of inflammation there
is seldom, I believe, much increase of volume even of the part
inflamed. Enlargement of the liver is much more common in
adhesive inflammation — that is, in inflammation which terminates
in effusion of coagulable lymph, and causes permanent induration,
or cirrhosis. This latter kind of inflammation, at least when
produced by spirit- drinking, usually involves the entire organ,
and apparently by causing an interstitial deposit of lymph, often
much increases its size; while suppurative inflammation is ge-
nerally limited to a small part of it, and before pus is formed,
even this part may be little increased in volume.
The circumstance, that suppurative inflammation is generally
partial, serves also to explain the occasional absence of jaundice.
A portion only of the liver is inflamed, and as any part can per-
form its function independently of the rest, the sound parts may
be adequate to free the blood of the principles of bile.
The presence, or absence, of seems to depend, not so
much on the extent, as on the situation, of the portion inflamed.
As long as the inflammation is confined to deep-seated parts,
82 SUPPURATIVE INFLAMMATION OF THE LIVER.
and is not sufficiently extensive, nor attended with sufficient con-
gestion to cause enlargement of the liver, and stretching of its
capsule, there is little, or no, pain. The substance of the liver,
like that of the lungs and other parenchymatous organs, is little
susceptible of pain. The sharp and severe pain that frequently
attends inflammation of these organs, has its seat in their fibrous
or serous covering.
The occasional absence of symptoms directly referable to the
liver, is not then so inexplicable as might at first appear. It is
satisfactorily accounted for by the circumstance, which dissection
has already disclosed to us — that suppurative inflammation is
generally partial, and often involves only the substance of the
liver, the natural sensibility of which is slight.
When suppurative inflammation involves all the secreting sub-
stance of the liver, there is deep jaundice, and the patient dies
from oppression of the functions of the brain. A case, which
seems to have been one of this kind, is given by Andral (Clin.
Med. iv. p. 381).
When an abscess in the liver has become encysted, if small
and deep-seated, it causes but little constitutional disturbance,
and, provided it remain stationary, the patient may enjoy even
tolerable health for years. I had clear proof of this in the case, to
which I shall again refer, of my late colleague, Mr. Lawson, con-
sulting surgeon to the Dreadnought, who for ten years before his
death had undoubtedly his liver studded with abscesses, but was
still competent to all the duties of his profession. If, however, the
abscess be large, the health is usually much broken. Even when
there is neither pain or tenderness, there is yet some degree of
fever ; the pulse is frequent ; there are night sweats ; and the pa-
tient does not recover strength ; and, not uufrequently, the urine
deposits a pinkish sediment. The complexion, too, has in most
cases lost its natural clearness, and is sallow or muddy.
But besides the general symptoms of inflammatory fever, and the
special symptoms — pain and tension in the right hypochondrium,
and jaundice — which occur in well-marked cases of suppurative in-
flammation of the liver, and which, when found in conjunction with
the circumstances in which suppurative inflammation is known to
arise, are perhaps sufficient to characterize it, there are some
other symptoms occasionally observed, which cannot be referred to
SYMPTOMS.
83
either of the preceding heads, and which frequently continue after
the feverish symptoms are past. These symptoms are, pain in the
right shoulder ; vomiting ; a short, dry cough ; and permanent
rigidity of the muscles of the abdominal parietes, but especially of
the right rectus muscle.
Pain in the right shoulder has long been noticed, — indeed from
the time of Hippocrates, — as an attendant on hepatic disease ; and
considerable importance has been attached to it, as a sign of
hepatic abscess. M. Louis, in his paper on abscess of the liver,
states that none of his patients (they were five in number), had
any pain in the shoulder ; and he hesitates to believe that this
symptom really belongs to disease of the liver. He conjec-
tures, that, when present, it may depend on concomitant
disease of the lung or pleura. Nearly the same opinion has been
expressed by M. Andral.
Pain in the right shoulder is, indeed, far less frequent in cases
of abscess of the liver than is generally imagined, but it existed in
five of the fifteen cases I had to treat at the Dreadnought, and in
some of these cases there could be no doubt that the pain in the
shoulder was dependent on the disease of the liver.
In one of these five cases there was a small abscess on the
convex surface of the right lobe, and the peritoneum covering the
abscess adhered, for the space of a shilling, to the reflected layer
of the peritoneum. There were some old adhesions of the lung to
the pleura costalis, but no trace of recent pleurisy. Both lungs
were pale and perfectly sound.
In another of these cases, in which the abscess was on the con-
vex surface of the liver, and formed a prominent tumor, the pain
of the shoulder was so severe as to cause the patient to moan.
The pain continued extremely severe for a long time, and at length
was relieved on our opening the abscess.
In a third case where the abscess likewise formed a prominent
tumor, the patient complained of an aching pain in the right
shoulder, extending to the shoulder-blade and up the right side of
the neck.
In a fourth case, pain in the shoulder varied in intensity with
pain in the right side. When the side was easy, the shoulder
was easy also. The two pains were evidently related. In this
case, there were five or six abscesses of various sizes in the liver —
g 2
84
SUPPURATIVE INFLAMMATION OF THE LIVER.
one opened into the lung ; another was on the convex surface of
the right lobe.
In the fifth case, the abscess was single, and was likewise si-
tuated on the convex surface of the right lobe. There was no
recent inflammation of the lung or pleura.
In two of these cases the pain in the right shoulder continued
for months ; and in all of them it was associated with pain in
the region of the liver. In all the cases there was an abscess on
the convex surface of the right lobe, aud adhesions had formed
between the peritoneum covering this abscess, and the layer of
peritoneum reflected over the diaphragm or abdominal parietes.
These cases tend to bear out a statement made by Annesley,
that pain of the right shoulder is a sure indication that the disease
is in the right lobe ; and they explain how it happened that pain in
the right shoulder was supposed to be so much more frequently
associated with abscess of the liver than it really is. Pain in the
right shoulder occurs chiefly in those cases in which the abscess is
situated on the convex surface of the right lobe. * Now, before
the practice of opening bodies had become general, it was only
when the abscess was so situated, and when it formed a prominent
tumor, that its existence was detected. The physicians of those
times, therefore, observed pain in the shoulder in a great propor-
tion of the cases in which they discovered an hepatic abscess;
whereas the frequent dissections made of late years have taught us,
that abscess is more frequently seated deep in the substance of the
liver than on its surface, and that pain of the right shoulder is
more frequently absent than present.
The pain is usually described as a gnawing, aching pain, about
the top of the shoulder. There is no swelling or redness of the
shoulder, and the pain is not much increased by pressure — some-
times indeed it is relieved by holding or pressing the shoulder —
but it is often increased by pressure on the liver. The pain is, in
fact, as it has always been represented to be, a sympathetic pain,
like the pain of the knee from disease of the hip.
This sympathetic pain in the shoulder is occasionally felt in
other diseases of the liver. It now and then occurs in cancer of
the liver, and it may even be produced by a tumor compressing
* Andral gives a case (t. iv. obs. 32), where there was pain in the right
shoulder, with abscess on the under surface of the right lobe.
SYMPTOMS.
85
the liver. It was complained of by a man who was admitted into
King’s College Hospital, under my care, in April, 1 843, with aneu-
rysm of the abdominal aorta. The man died suddenly from burst-
ing of the aneurism, between four and five weeks after his admission.
The aneurysm, which sprung from the side of the artery oppo
site the origin of the caeliac axis, formed a tumor as large as a
man’s head immediately behind the liver. It had partially de-
stroyed the bodies of the first, second, and third lumbar vertebrae,
and had very much flattened the liver. The tissue of the liver
was quite healthy, and the capsule presented no marks of ever
having been inflamed.
The cough and the vomiting, are symptoms of the same kind.
Irritation of the liver, like irritation of the stomach, produces a
short, dry, sympathetic , cough ; and, like irritation of most of the
abdominal viscera, it may occasion vomiting.
M. Louis has not only thrown discredit on pain of the
shoulder, as a symptom of hepatic abscess, hut has advanced
similar opinions respecting the vomiting and cough. The vomit-
ing he supposes to arise from inflammation of the mucous mem-
brane of the stomach ; and the cough, to he the consequence of
bronchitis.
I have had several opportunities of satisfying myself that the
opinion of this eminent pathologist on these points, is incorrect ;
and that the cough and vomiting, so frequently observed in
abscess of the liver, do not depend on any disease of the lung
or stomach, but are what I have stated them to be, sympathetic
disorders, depending solely on irritation of the liver.
In the autumn of 1837, a sailor, 29 years of age, was admitted
into the Dreadnought, immediately on his arrival from Calcutta.
He was much emaciated, and stated that he had been ill thirty
days of fever, and that during the last ten days, he had vomited
everything he had taken. His belly was much drawn in, and the
parietes were extremely rigid, hut there was no tenderness on
pressure. He was somewhat thirsty, hut afraid to drink, on ac-
count of the vomiting it immediately excited. My impression was
that his disease was gastritis, and I prescribed for him ac-
cordingly. The symptoms increased, and at the end of a fortnight
he could he got to take little besides toast and water, which he
sipped rather than drank. He died about a month after his ad-
10
86
SUPPURATIVE INFLAMMATION OF THE LIVER.
mission to the Dreadnought. The stomach was found apparently
sound, hut the liver was the seat of a large abscess, the presence
of which was not even suspected.
It has been mentioned that in this case, although there was no
pain or tenderness, the abdominal parietes were constantly in a
state of rigidity. I remarked the same symptom in several of the
other cases. In one of them it was very striking : the abdominal
parietes were hard, like board, especially on the right side, with the
skin loose over them.
Rigidity of the right rectus muscle was, I find, noticed by the
late Mr. Twining, and considered by him, and some other surgeons
in India, as one of the surest indications of deep-seated abscess of
the liver. Like the other symptoms with which it is here associated,
it is a purely sympathetic affection. It is now and then met with
in other diseases besides abscess of the liver. I observed it in a
case of long-continued jaundice from closure of the common duct,
which is related in another chapter; and also, in a very striking
degree, in a case where a cancerous ulcer of the stomach had eaten
into the liver, to which the stomach adhered. It is noticed in a
case of inflamed gall-bladder, published by Dr. Graves, of Dublin,
and which is cited at length in a subsequent chapter.
These sympathetic affections — the pain in the right shoulder,
the vomiting, the cough, the rigidity of the abdominal muscles are
of very doubtful import in the early stage of suppurative inflamma-
tion, while there is yet much fever ; but when they exist after the
acute stage has passed and the fever has subsided, and at the same
time present the characters above noticed — when the pain is seated
about the top of the shoulder, is unattended by redness or swelling,
and is not much increased by pressure on the shoulder, but by
pressure on the side — when the cough is short and dry, and can-
not be explained by the condition of the lung — when the vomiting
occurs, immediately after food or drink has been taken ; which is
a general character of sympathetic vomiting — when, in fact, these
symptoms have the characters of sympathetic affections, they are
strong indications of the existence of an hepatic abscess.
The symptoms that have now been enumerated are almost the
only symptoms of suppurative inflammation of the liver, or of its
termination — abscess — while the abscess is confined to the sub-
stance of the organ.
SYMPTOMS.
87
Rut when the abscess is large and near the surface, it may, ac-
cording to its situation, discharge itself in various ways. If
situated on the outer surface of the liver, it may either hurst into
the cavity of the peritoneum, or, by means of adhesion, make its
way through the abdominal parietes ; if it he situated on the upper
part of the liver, in contact with the diaphragm, it may perforate
the diaphragm and burst into the cavity of the pleura, or adhesions
may form between the lung and the portion of diaphragm covering
the abscess, and the abscess may open into the lung, and be dis-
charged through the bronchial tubes ; if the abscess be near the
edge, or on the under surface of the liver, adhesions may form
between the peritoneum covering it and the stomach, duodenum,
or large intestine, and the matter be discharged through the in-
testinal canal.
There will, of course, be a variety of symptoms indicative of
these several results.
If the abscess burst into the cavity of the peritoneum, there
will be sudden accession of pain, vomiting, and all the symptoms
of peritonitis from perforation. The patient will speedily fall into
collapse, and survive, at most, a few days.
If, however, the matter discharge by oozing merely, it may not
become diffused over the surface of the peritoneum, to excite
general peritonitis. It will spread over the liver, and will be
limited by adhesions so as to form a circumscribed abscess in the
cavity of the peritoneum. This mode of termination is noticed by
Craveilhier, and happened in two of the cases that fell under my
own observation at the Dreadnought.
If the abscess open into the stomach, there will be sudden
vomiting of purulent matter ; if into the intestines, sudden
diarrhoea, with discharge of pus ; — and, in either case, the occur-
rence of these symptoms will be attended by subsidence of the
tumor, if any exist.
If the abscess perforate the diaphragm, it may open into the
cavity of the pleura, and excite suppurative pleurisy ; but this
seldom happens. In almost all cases in which the abscess is
making its way through the diaphragm, it excites inflammation
of the pleura immediately above it ; and adhesion, which is some-
times singularly limited, takes place between the diaphragm and
the lung. The abscess then opens into the lung, and the matter
is discharged through the bronchial tubes. When this happens,
88
SUPPURATIVE INFLAMMATION OF THE LIVER.
it is marked by very characteristic symptoms, — by a new train of
stethoscopic phenomena, which it is, perhaps, unnecessary to
detail, and by the sudden expectoration of a dirty red or brownish
puriform matter. The peculiar colour of this matter, which
has been already noticed, arises from the pus, in its passage
through the lung, becoming mixed with blood and broken down
pulmonary tissue. There is no matter like it expectorated in any
disease of the lung itself, and I believe that its appearing is
pathognomic of abscess of the liver, or, at least, of abscess per-
forating the lung. I observed it in several instances in the
Dreadnought, and more than once was led by it to detect an
abscess in the liver, of which I had previously no suspicion.
When the abscess is large, this matter may continue to be spit up
for a great length of time. It generally comes up very easily, in
some cases by mouthfuls, almost without effort on the part of the
patient.
When an abscess of the liver opens into the intestines or into
the lung, all the matter may be discharged, the cavity may close
up, and the patient recover. I have met with one instance, in
which a patient who had all the symptoms of abscess of the liver
discharging through the lung, so far recovered that he left the
hospital apparently well. But such a happy result is very rare,
and happens, I imagine, only when the abscess is small or recently
formed. In the majority of cases, the patient dies, exhausted by
protracted suppuration and hectic.
The protracted suppuration depends on the nature of the walls
of the abscess. The hepatic tissue and the hard gristly substance
that always surrounds an old abscess of large size, cannot
contract so as to close the cavity, which must consequently con-
tinue to be filled with pus. The case is analogous to those cases
of old empyema, in which the lung is condensed and irrecoverably
bound down against the vertebral column. In such cases, the
fluid, if serous, continues to be absorbed, as long as the contrac-
tion of the side, the encroachment of the apposite lung, the dila-
tation even of the bronchial tubes of the compressed lung, con-
tinue to diminish the pleural cavity of the diseased side ; but when
all these means have reached their limit, and the cavity can be
made no smaller, an end is put to the absorption of the fluid.
It is a physical impossibility that a drop more of the fluid can be
absorbed. In the same way, in old abscesses of the liver, if the
TREATMENT.
89
hardened tissue about tbe abscess cannot contract so as to close
the cavity, the cavity must continue to be filled by pus.
It is, then, to the unyielding nature of the walls of the cavity,
that we must ascribe the protracted suppuration, and the fatalness
of hepatic abscess, even in cases in which the free discharge of
the pus would seem to promise a more favourable issue. The
fatalness has no relation to the outlet by which the matter is
discharged. I have met with several cases in which the abscess
opened through the abdominal parietes, and all of them proved
fatal, so that it seems doubtful whether such an opening be more
favourable than one into the intestine or lung.
The abscess, if large, may discharge through more outlets than
one. In one of the cases I treated at the Dreadnought, the abscess
discharged first through the lung, and afterwards through the
abdominal parietes also. The reason of this is, that from its
sides not collapsing, the abscess is not emptied through the first
opening.
It has been supposed by some medical men in India, that the
pus in an abscess of the liver may be absorbed, and eliminated, as
j)tfs, in the urine. But this notion is evidently erroneous. Pus-
globules, from their large size, cannot directly enter the blood-
vessels or escape from them. The matter in the urine supposed to
be pus, was probably a deposit of phosphates. During the
severe constitutional disorder that attends purulent phlebitis,
there is often a sediment of this kind in the urine, — having
to the naked eye much the appearance of pus, but under the
microscope, showing, instead of pus-globules, beautiful phosphatic
crystals.
The treatment of suppurative inflammation of the substance of
the liver is very unsatisfactory.
When the inflammation is caused by phlebitis consequent on a
wound or injury of the head or limbs, the whole mass of venous
blood is contaminated by pus, suppurative inflammation is like-
wise set up in many lobules of the lungs, perhaps in some of the
joints, and, it may be, in various other parts of the body ; and the
patient soon falls into a typhoid state, which bleeding and other
lowering measures would only make worse. The inflammation
thus excited passes rapidly on to suppuration, and we have little,
if any, power to arrest it.
90
SUPPURATIVE INFLAMMATION OF THE LIVER.
The chief objects of treatment should be, to prevent, where this
is possible, the passage of any more pus into the blood from the
injured part, and to support the strength of the patient.
When suppurative inflammation of the liver is caused by a blow,
the lungs and other organs do not suffer as in purulent infection
of the blood : neither are they thus implicated, when it is induced
by ulceration of the stomach, or intestines, or gall-bladder, since,
in these cases, the noxious matter which excites the inflammation
is detained in the liver or drained off through it. Here, the
strength of the patient is not so profoundly sunk, and we may
hope, by means of depletion, especially by local bleeding, to con-
trol the inflammation, and limit its extent ; and, by rendering the
abscesses smaller, to protract, at least, the patient's life. In some
cases we may, perhaps, by active measures employed early, prevent
matter from forming, but we have no evidence that this can be
done when the inflammation is caused by pus, and is the conse-
quence of inflammation of one of the veins that return their blood
to the portal vein.
In this country, mercury has generally been resorted to, when
the local symptoms have led to the suspicion that the liver was
diseased ; but, I fear, with no benefit to the patients. It has
been well observed by Abercrombie, “ In the liver- diseases of this
country, mercury is often used in an indiscriminate manner, and
with very undefined notions as to a certain specific influence,
which it is supposed to exert over all the morbid conditions of this
organ. If the liver be supposed to be in a state of torpor, mer-
cury is given to excite it ; if in a state of acute inflammation,
mercury is given to moderate the inflammation and reduce its
action.”
This indiscriminate use of mercury has resulted from its un-
questionable efficacy in some derangements of the liver, and from
the difficulty of distinguishing the different disorders of this
organ. In doubt as to the real nature of the malady, the practi-
tioner is naturally anxious to give his patient the chance of a
remedy that occasionally produces marked benefit; but often, in
doing so, aggravates the disorder it is his object to relieve.
This misapplication of mercury will continue until the various
diseases and derangements of the liver are better discriminated,
and practitioners bave ascertained those in which mercury has a
curative influeuce. There can be no doubt, that much of our
TREATMENT.
91
uncertainty as to the action of this ancl other medicines, arises
from our confounding under the same name, and treating in the
same manner, diseases that spring from different causes, and are
essentially different in their nature.
It seems to me that mercury is peculiarly unsuited to the dis-.
ease we have been considering — suppurative inflammation of the
liver.
One objection to its employment in this disease, is the short
time allowed for its action. When the inflammation is consequent
on a wound or injury, and also, in all probability, when it occurs
in the course of dysentery, it passes on to suppuration in two or
three days ; and when suppuration has once taken place, and
abscess has formed, it is agreed by all who have had experience
on the subject, not only that mercury does no good, but that
in whatever quantity it be given, it fails to produce its usual con-
stitutional effects. This fact, singular as it may appear, seems to
be fully established. Annesley says, “ There can be no doubt
that the system will not be brought under the full operation of
mercury, or that ptyalism will not follow on the most energetic
employment of this substance, where abscess exists.”
He repeats this opinion again and again, and even considered
resistance to the action of mercury, a proof that abscess had
formed in the liver.
It is only, then, before suppuration has taken place, that mer-
cury can do any good, and during this time, from the presence of
high fever, the system is with difficulty affected by it.
When abscesses have formed and become encysted, the time for
active treatment by medicine has of course passed away. The wisest
course, then, is, I believe, merely to regulate the bowels by rhu-
barb, or rhubarb and aloes, to recommend habits of strict tem-
perance, and, where the circumstances of the patient allow,
residence in a mild climate. If the complexion be sallow or
dusky, the nitro-muriatic acid, as recommended by practitioners
in India, will often be productive of benefit. Whenever there is
reason to infer, from increase of pain and fever, that fresh inflam-
mation is set up within the cyst, and that the abscess is growing
larger, blood should be taken from the side by leeches or cupping,
or a blister should be applied there.
Many physicians have recommended that abscesses of the liver
should be opened ; but there is much danger in the practice.
One source of danger, noticed by Annesley, Dr. ^Stokes, and
92
SUPPURATIVE INFLAMMATION OF T1IE LIVER.
many other writers, arises from the difficulty of distinguishing an
hepatic abscess, and our liability to mistake a distended gall-
bladder for an abscess. Such a mistake is almost immediately
fatal to the patient. A distended gall-bladder is seldom adherent
to the abdominal parietes, and if it be punctured, the bile escapes
into the cavity of the peritoneum, the patient is seized with vomiting,
falls rapidly into a state of collapse, and generally dies at the end
of a few hours. Two cases of this kind are alluded to by Dr.
Stokes, in the fifth volume of the Dublin Hospital Reports, and
many others are on record. This source of danger may, however,
be avoided by attention to the situation and character of the
tumor. The tumor formed by a distended gall-bladder is globular,
and circumscribed, and hard, and equally resisting in every part,
while the tumor from abscess is more diffused, and is soft and
fluctuating at its summit, while its base is hard and resisting.
A source of far greater danger is the circumstance, which has been
before noticed, that the inflammation which leads to abscess, is
often confined to the substance of the liver and does not involve its
capsule. As the abscess approaches the surface, adhesive inflam-
mation of the peritoneum immediately above it often takes place,
and a small quantity of lymph is poured out, which causes
adhesion between the wall of the abscess and the parts with which
it is brought into contact. These adhesions are often of very
small extent. Sometimes, they do not form at all, and as I
have before remarked, the abscess bursts into the cavity of the
peritoneum, causing speedy collapse and death. By opening an
abscess of the liver before adhesions have formed, we may be di-
rectly instrumental in bringing on this fatal issue — the pus may
escape into the sac of the peritoneum, and the patient die in a
few hours, obviously in consequence of the operation.
I would, then, never recommend opening an abscess of the
liver, unless assured by circumscribed oedema, or a slight blush on
the skin, that union had taken place between the integument and
abscess. When these signs are wanting, and the skin has its
natural appearance and colour, we can never be sure that adhesions
have formed, and if we thrust a knife into the abscess, we run the
risk of discharging the matter into the cavity of the peritoneum.
Dr. Graves has ingeniously recommended a mode of proceed-
ing, by which he supposes this danger may be obviated. It is,
not to open the tumor at once, but to make an incision across the
most prominent part of it through the abdominal muscles, so as
TREATMENT.
93
to reach the peritoneum, without dividing it, and to fill up the
wound with a pledget of lint. The object of this is, to excite
circumscribed inflammation of the peritoneum, which may pro-
duce adhesion between the reflected layer of the peritoneum and
the layer covering the abscess. The abscess is then allowed to
open of itself. I have tried this mode of proceeding twice, but
with very unsatisfactory results. There is, indeed, a third source
of danger in opening abscesses of the liver, which has not been
noticed by the writers to whom I have referred : — it is, that by the
entrance of air into the wound, fresh inflammation may be ex-
cited, which may lead to gangrene, and speedily carry off the
patient. This circumstance happened in one of the cases I
treated in the Dreadnought. An abscess that pointed outwardly,
was opened, with considerable temporary relief to the pain which
the patient suffered in the side and shoulder. But the discharge
became fetid and dark, of the colour of coffee-grounds, and the
patient sunk, and died at the end of a week. The walls of the
abscess and the hepatic tissue immediately around them were
found in a state of gangrene. A similar case is noticed by Cru-
veilhier. ( Anat . Path. liv. xl.)
In opening old abscesses of large size there is a fourth source of
danger. It has been already remarked that the walls of such
abscesses are generally very firm and unyielding, and cannot col-
lapse so as to close the cavity when the abscess is opened. When
an abscess of this kind opens of itself, either outwardly, or into
the intestine or lung, matter continues to be discharged, and the
patient generally dies, worn out by the protracted suppuration.
When the abscess is opened by the knife, the same thing of
course happens, and the patient dies the earlier for our meddling.
In India, it seems now to he a common practice, to thrust a long
exploring needle into the liver, where the presence of an abscess
is suspected ; and, now and then, perhaps the disease may be
cured in this way. A single abscess may be opened, when it is of
moderate size, and before its walls are too thick and firm to fall
together, and the cavity may be closed up. But there are
many objections to the practice that to me seem quite decisive
against it. First, there is the danger of hemorrhage, and of set-
ting up fresh inflammation by the mechanical injury thus done to
the liver. This danger may, perhaps, be small for a single punc-
ture, but if the abscess be deep-seated, it may not be hit at the
94
VARIOUS FORMS OF
first thrust. Again, from the difficulty of distinguishing the
different diseases of the liver, if the operation be commonly
adopted, it must often be performed where there is no abscess at
all. It will readily he imagined that much mischief may be done in
this way. Often, too, there is more than one abscess. This was
the case in thirteen of the twenty-nine cases recorded by An-
nesley, and in a still larger proportion in the cases collected by
Andral and Louis, and myself. We can hardly hope to reach all
the abscesses, and unless we do, we cannot cure the patient.
Then there is the danger that has been before alluded to, of letting
the matter escape into the sac of the peritoneum, and setting up
peritonitis that may prove speedily fatal. An occasional instance
of success will, I fear, he a poor set-off against the cases in which
the operation has done mischief, or failed of doing good.
Hitherto, we have considered only suppurative inflammation
originating in the lobular substance of the liver. There are
several other forms of suppurative inflammation of this organ, hut
they are much more rare.
1st. One of these is where the inflammation originates in the
areolar tissue in the portal canals and where the pus, instead of
forming a circumscribed abscess, is diffused through the areolar
tissue that surrounds the portal vein and the accompanying artery
and duct. A case of this kind is given by Cuveilhier.
A professional flute-player, of intemperate habits, after long anxiety, fell
into a state of extreme weakness, attended with feverishness, for which he
sent for Craveilhier, on 18th of December, 1818. His face was then pale, and
thin, he had distaste for food, a short dry cough, and a slow fever with
evening exacerbations.
Cruveilhier examined the chest and abdomen, without discovering the
cause of illness. The symptoms continued, the patient grew thinner, the
tongue became very dry and brown ; and, at length, the patient fell into a
typhoid state, and died on the 5th of February. On examination, pus was
found diffused through the areolar tissue surrounding the branches of the
portal vein, in the substance of the liver. The lobular substance of the liver
was perfectly healthy. There were also small abscesses along the vessels in
the meso-colon and meso-rectum. The state of the intestines is not men-
tioned.
2nd. Another form is where suppurative inflammation is set up
in the capsule of the liver, or in the peritoneum covering it. This
may take place without suppurative inflammation of the substance
SUPPURATIVE INFLAMMATION OF THE LIVER.
95
of the liver, and, at first, without inflammation of the rest of the
peritoneum. But, when pus has formed on the surface of the
liver, it becomes diffused over the surface of the peritoneum, and
causes general and rapidly fatal peritonitis, just as when dis-
charged by the bursting of an abscess. A case of this kind is
given by Andral (Clin. Med. iv. 310). It would seem that in
such cases the material cause of the inflammation, if such exist, is
conveyed by the arterial blood.
3rd. A third variety of suppurative inflammation is where the
inflammation originates in the portal or hepatic veins. This
variety is so important that I shall consider it in a separate
chapter.
4th. A fourth variety is where suppurative inflammation occurs
in the gall-bladder or ducts, without similar disease in the secret-
ing substance of the liver. This, too, is so important, that I shall
speak of it in a separate chapter.
5th. There is still another variety, where suppurative inflamma-
tion is set up in the interior of an hydatid cyst, converting it into
an abscess. This, considering the rareness of hydatids in the
human liver, is not of unfrequent occurrence. One instance of it
has fallen under my own notice. Three are recorded by Andral,
and two or three by Cruveilhier. The fragments of hydatids were
found floating in pus. The observations of Cruveilhier render it
probable, that, in most of such cases, the suppurative inflammation
is set up by the entrance of bile into the cyst. These cases will
be again referred to in a subsequent chapter on hydatids of the
liver.
9G
Sect. II. — Gangrenous inflammation — Appearances sometimes
mistaken for gangrene— Circumstances in which gangrene of
the liver really occurs.
The infrequency of gangrene of the liver has been remarked
by Annesley, Dr. Stokes, and many other writers. Annesley states
that he did not meet with a single instance of gangrene in all the
subjects he examined with abscess and other diseases of the liver ;
and supposes that medical men have often mistaken for gangrene,
changes that occurred after death. I have little doubt that
Annesley is right in this opinion. If the abscess he re-
cently formed and not encysted, and the body he examined after
the matter in the abscess has become partly decomposed, the
hepatic tissue immediately surrounding the abscess will he found
blackened by the sulphuretted hydrogen, formed by decomposi-
tion of the pus. A black stain is often found on that part of the
surface of the liver which touches the intestine, produced in the
same way by the intestinal gases, which, after death, permeate the
coats of the bowels.
In persons who die of suppurative peritonitis, the whole sur-
face of the liver soon acquires a black colour, which extends a
line or two into its substance, — the deeper, the longer after death
the body is examined. Now and then, in cutting across a liver,
we find a black stain of the same kind, in the portions of liver in
contact with the gall- ducts, produced, no doubt, by permeation
of sulphuretted hydrogen, or other gases, through the coats of the
ducts.
In the month of July, 1837, a man died in the Dreadnought,
under my care, with a recently formed abscess of the liver. The
body was examined forty hours after death. In the upper part of
the right lobe of the liver, was an abscess containing more than
a pint of matter. There was no false membrane surrounding the
abscess, and the hepatic tissue about it was black and ragged.
The time after death, at which the examination was made, in the
GANGRENE OF THE LIVER.
97
month of July, enables us to account for the black colour of the
hepatic tissue about the abscess, without supposing that it was
the effect of gangrene.
In the following case, for which I am indebted to my friend
Mr. Busk, a similar appearance of the hepatic tissue about a
recently formed abscess was observed twenty-four hours after
death, at the end of March ; but here the patient died in a low
typhoid state, from contamination of the blood by pus, and the
decomposition after death was unusually rapid.
Case. — Contused wound of the little finger — About a month afterwards, vio-
lent rigors, followed by typhoid symptoms — Death on the seventh day — Dis-
coloration of the skin of the neck — Gas in the vena cava — Collections of
pus in both lungs and in the left wrist — Small abscesses in the liver, not en-
cysted— Hepatic tissue about them of a blackish-green — Another abscess in
the liver bounded by a cyst.
A sailor, aged 27, was admitted into the Dreadnought on the 28th of Fe-
bruary, 1835, with a contused wound of the little finger of the left hand, in-
flicted several days before.
In about three weeks, he had so far recovered as to be able to return to his
duty. However, on the night of the 24th of March, he was seized with
severe and long- continued rigors, under one of which he was labouring when
seen in the morning. He did not complain of pain, but only of repeated
rigors, and a feeling of general weakness. The pulse was very frequent and
weak. The rigors continued to recur frequently, and the following night
bilious vomiting came on. The bowels were well opened. In the morning
of the 26th, he was much collapsed — the surface cold and the countenance
dusky and livid — but still, he had no pain, and his senses were perfect. He
had no cough, or other apparent symptom of disease of the lungs. Pulse,
120, very weak. On examining the belly, it was observed that he had
been repeatedly cupped at the epigastrium and both hypochondria, which he
stated to have been done for an attack of yellow fever, eighteen months be-
fore. By firm pressure an obscure sense of pain in the right hypochon-
drium could be elicited, and he acknowledged slight occasional pain in the
right shoulder, and in the right side of the chest. The urine was natural in
appearance and quantity. Tongue, furred and moist. Thirst, very great.
On the 27th, there appeared to be some degree of re-action, with flushing
of the face and hot skin. The tongue became dry and glazed. Pulse, 120,
sharp, with considerable power. The pain in the side had not increased, and
was felt only on pressure. He was bled to fainting (fourteen ounces), and
twenty leeches were applied to the side.
On the 28th, he was much in the same state. Tongue, dry and brown.
He was bled again, but fainted before four ounces of blood had flowed.
On the 30th, he had frequent cough, and spat up a dark brown matter,
which was very viscid and fetid. He was now slightly delirious, and
H
com-
98
GANGRENE OF THE LIVER.
plained of severe pain in the left wrist, the back of which was swollen. Skin,
hot. Pulse, 120, weak.
On the 31st, (the seventh day,) he had convulsive twitchings of the arms
and hands, and of the right side of the face. He became comatose, and died
in the afternoon.
The body was examined twenty-four hours after death.
The face and neck were of a deep purple ; and the lower part of the neck,
to a short distance below the clavicles in front of the chest, had already
become green. The belly was not discoloured. The leech-bites had assumed
the appearances of pustules, being filled with white matter of most repul-
sive smell. The body was but little wasted, and the rigidity of the muscles
was considerable.
Head. The vessels of the pia-matter were very turgid, and there was some
purulent matter on the surface of the anterior lobes. There was also some
effusion beneath the arachnoid, at the base of the brain. The cerebral mass
was otherwise in natural condition.
Chest. The blood contained in the large vessels was fluid, and numerous
bubbles of air escaped from the superior vena cava, when this vessel was
divided. Both lungs were studded with purulent deposits of various sizes,
between which the pulmonary tissue had its natural appearance and firm-
ness, and crepitated under the finger. These deposits were found in all
parts of the lungs, but were most numerous and largest in the posterior two-
thirds of the right lung. The left lung in the corresponding part was much
congested. The deposits had not the character of abscesses ; but in their
seat the pulmonary tissue was pale and infiltered with pus. The patches thus
formed were of irregular shape, without defined margins. In the upper and
middle lobes of the right lung were also several small tubercular cavities.
These were most numerous in the upper lobe, but the largest of them were
in the middle lobe. The heart was healthy, and contained fluid blood. Its
lining membrane was stained of a dark red, and the pericardium contained a
small quantity of reddish serum.
Abdomen. On theabdomenbeing opened, nomorbid appearance was observed
at first, but on the hand being passed backwards to raise the liver, it broke
into a large irregular cavity in the upper and back part of the right lobe, and
on examination about one-third of that lobe was found in a state of complete
gangrene. The gangrenous portion was of a blackish -green colour, and very
friable. In the midst of it were several collections of thick white pus. The
cavities in which this matter was lodged were very irregular, and were not
bounded by a false membrane, but merely by the ragged hepatic substance.
Near the gangrenous portion, and deep in the substance of the liver, there
was another abscess, which was bounded by a thick white false membrane.
The rest of the liver was of a pale colour, and the gall-bladder contained thin
colourless mucus. The spleen was large, but appeared healthy. The kidneys
were soft, and gorged with blood. The other viscera were quite healthy.
The left wrist contained a small quantity of bloody pus.
In this case, the cavities in the right iung and the encysted
CAUSES.
99
abscess in the liver, appeared to be of some standing, and pro-
bably existed before the injury was done to the finger. The other
collections of pus in the lungs, and the abscesses in the liver
that were not encysted, seem to have been of more recent date,
and were, no doubt, formed, like the abscess in the left wrist, the
week before death, after the occurrence of the rigors.
It is probable that the black colour of the hepatic tissue about
the abscesses that were not encysted, did not depend on gangrene,
but that, like the green colour of the skin in the lower part of the
neck, it came on after death, in consequence of decomposition ;
and that the cyst that surrounded one of tire abscesses, by pre-
venting the permeation of the gases thus formed, prevented the
blackening of the hepatic tissue about it.
In old abscesses bounded by thick and dense false membrane,
this change in the colour of the surrounding hepatic substance
is less likely to take place after death, and as an effect of mere
chemical change ; and, consequently, a blackish- green colour is
here a surer sign of gangrene.
An instance of gangrene occurring about an old abscess, which
has been referred to in the preceding chapter, (p. 65,) is given by
Andral ; the only instance, he tells us, in which he had then met
with gangrene of the liver. The patient, a labouring man, about
60 years of age, was much emaciated, in consequence of an ex-
tensive chronic ulcer of the stomach.
The gangrene, or death of the part, was probably the result
of defective nutrition. It occurred around the abscess, just
as a bruise-mark or ulcer occurs in the place of an old scar in
scurvy, because the vitality of that part having been previously
injured, it gives earlier tokens of defective nutrition than the
sound parts.
The following case, for which I am indebted to Mr. Busk, is the
most striking instance of gangrene of the liver I have met with,
and offers besides many points of great interest.
Case. Mortification of the toes from cold — Removal of the dead parts —
Severe rigors followed by typhoid symptoms — Death on the sixth day —
Gangrene of the liver, the lung, and the spleen; Necrosis of the thyroid
cartilage ; ulceration of the pharynx ; pus in the shoulder-joint.
A Scotchman, 35 years of age, was admitted into the Dreadnought, the
14th of January, 1841, with the extremities of the two great toes, and of
II 2
100
GANGRENE OF THE LIVER.
several other toes, in a state of gangrene, from exposure to cold in coming up
the channel, after a voyage to the West Indies. He had good health while
in the West Indies, but, with the rest of the crew, had drunk rum to excess
in the voyage home.
There was little appearance of inflammation, and but little pain in the feet,
and he was otherwise in good health : spare, muscular, and rather florid.
In a few days, under the use of warm fomentations, the dead parts began
to separate from the living, and on the 25th of January, the separation was
nearly complete at the junction of the second and last phalanges, which were
then removed, sufficient flaps being left to cover the bones. The day after
this little operation, he had rigors followed by incessant vomiting and great
general disturbance. The rigors recurred very frequently, and the vomiting
continued incessant. No pain or tenderness could be detected in any part.
In a day or two he became jaundiced, and expectorated rusty-coloured, viscid
matter. The motions were clay-coloured. The tongue was dry and brown.
On the 29th, several joints, especially the right shoulder, were painful
and tender, but he had no pain or tenderness of the abdomen or chest. The
following day, mild delirium; finally, stupor, and death on the 1st of Fe-
bruary, (the 6th day from the rigors).
The body was inspected twenty-fours hours after death.
The body was lean, muscular, universally rigid, jaundiced, with dark
purple mottling on the hack and on the sides of the neck and ears.
Head. The dura mater on the outside looked healthy. Its inner surface
was minutely vascular, and covered by a thin film of fibrinous matter, of a
bright yellow colour, and presenting many minute spots resembling ec-
chymoses. On examination, these spots were found to be entirely in the
effused matter. The cerebral arachnoid was also covered, but over a smaller
surface, by a similar film of transparent, yellow, gelatinous-looking fibrine,
which, however, was not vascular, and but very slightly opaque. There
was a small quantity of liquid of a bright yellow colour in the cavity of the
arachnoid, and also some colourless fluid beneath it. The vascularity of the
arachnoid and the film of fibrine were alike on the two sides, and were confined
to the upper surfaces of the hemispheres. At the base of the brain, there was
no unnatural vascularity, and no lymph effused.
The cerebral substance, when sliced, presented large bloody points, more
numerous in the back part of the brain, but otherwise it looked healthy, and it
had its natural consistence. There was a very small quantity of colourless
liquid in the lateral ventricles.
Chest. Both lungs were everywhere united to the side by firm old tissue.
The upper and front part of the right lung was congested, but still crepi-
tant, and slightly infiltered with reddish frothy fluid. The lower and back
part of the lung was more solid, and gorged with thin red fluid ; and in
the midst of the lower lobe, which was quite solid, was a portion, the size
of an orange, completely gangrenous. The gangrenous part was of a
pale ash colour, mottled by infiltration of white pus, and had the extremely
offensive odour of gangrene of the lung. This dead portion was separated
by a well-defined line from the surrounding pulmonary tissue, which was of
CAUSES.
n 01
a deep purple colour, solid, and friable. Many other portions of the lung
were quite solid, and beginning to lose their colour, and others were in the
first stage of inflammation, but none had exactly the usual appearance of
pulmonary purulent deposits.
The left lung was in a similar state, but less advanced.
Both lungs had a most disgusting smell.
The mucous membrane of the right ventricle of the larynx was ulcerated,
and of a deep purple colour. The mucous membrane of the air-passages
was injected throughout, the colour becoming deeper in the small tubes.
There was a large ragged abscess outside and in front of the thyroid car-
tilage, which was bare and carious.
The pericardium contained a large quantity of red fluid, and the right
auricle and ventricle were filled with very fluid blood, and a few yellowish
flakes of fibrine. The valves and the lining membrane of the heart were per-
fect and unstained. The blood in the large vessels was dark coloured and
fluid, with small, soft coagula. No pus globules could be distinctly ob-
served in the blood examined by the microscope.
Digestive organs. The mucous membrane of the pharynx presented one
or two small superficial ulcers or abrasions, covered with a thin fibrinous
effusion, and was of a deep purple from minute vascularity. The deep colour
ceased on a level with the upper edge of the thyroid cartilage. The mucous
membrane of the oesophagus was pale and healthy.
The stomach was not examined.
The intestines, small and large, were healthy throughout, without any en-
largement of either Peyer’s patches or the solitary glands. The foecal matter
was of a pale clay colour-
The liver was large and closely united to the under surface of the dia-
phragm by firm old tissue. On the outside, it was not discoloured, and
presented no marks of recent inflammation. When it was cut into, numerous
ragged cavities of various sizes were found, containing hepatic substance in
a state of complete gangrene, and reduced in many of them to a semifluid,
ash- coloured, flocculent matter, separated by a very defined line from the
surrounding substance, which in immediate contact with the gangrenous
portions was of a deep greenish slate colour. In other spots less completely
disorganized, the hepatic substance was of a pale ash-colour, apparently quite
dead, but the lobular structure could be plainly seen ; thus proving clearly
that there was little or no deposit of foreign matter. Other portions again,
alike in size and shape, were of a deep purple, and slightly softened ; and
this was probably the first step in the changes leading to the complete dis-
integration first described.
The coats of the large veins, where they came in contact with the gangre-
nous portions, partook in the change, in consequence of which their inner
surface had a mottled appearance, the dead portions being of a dull yellowish
white, separated from the healthy part by a very delicate red line.
The inner surface of the vein was not roughened, or otherwise altered, either
in the dead or living parts, and had no lymph on it, either adherent, or free;
but in some of the larger veins pus was found. Several small gangrenous
102
GANGRENE OF THE LIVER.
spots of the liver were found, which had a small vein in their centre, and
there the coats of the vein in all their circumference were dead and dis-
coloured.
The gangrenous portions of the liver were horribly fetid, but still, less so
than those of the lung.
The gall-bladder contained a small quantity of thick, viscid bile.
The spleen was closely united to all the surrounding parts by firm old
tissue. Its middle portion was reduced to a grumous pulp. Nearer the
surface its substance was firmer, and of a dark purple colour, and had the
smell of gangrene.
The kidneys were healthy and pale.
The right shoulder-joint was filled with thick, fetid pus.
In this case, the existence of gangrene, hotli in the liver and
in the lung, was clearly shown hy the defined fine surrounding
the gangrenous portions.
The source of the mischief here was, no doubt, the gangrene
of the toes produced hy cold. The man was in the prime of life,
of spare habit, muscular, florid, and in good health at the time
of the frost-bite. The case shows us what a serious thing a
small patch of gangrene in any part of the body may become.
The dissemination of the gangrenous masses — the existence of a
number of them isolated and at a distance from one another —
proves that the septic agency was conveyed by the blood. The
noxious matter thus disseminated destroyed the vitality of the
tissues on which it acted most strongly.
The chemical theory of these septic changes is now well known.
All parts in which they are taking place, have a tendency to affect
other parts brought into contact with them, with the same mode of
transformation. The case just related, — and it is hy no means a
solitary one, — offers one of the most interesting illustrations of this
theory in the whole range of pathology. But, whatever he the ex-
planation adopted, the fact is certain, and it is one of extreme im-
portance, that gangrene of the extremities, or of any part of the sur-
face of the body, produced hy cold, hy pressure, or in any other
way, has a tendency to infect other and remote parts of the body
with the same change.
The occasional occurrence of gangrene in remote parts of the
body in low fevers, after sloughing of the skin of some one part
has been caused hy pressure, was particularly noticed hy Dr.
Graves, in his remarks on an interesting case in which gangrene
ol the lung was consequent on sloughing of the sacrum from
pressure.
CAUSES.
103
The patient, a man, twenty-four years of age, died in Sir
Patrick Dun’s Hospital, the twenty-ninth day after the first ap-
pearance of confluent small-pox. Dr. Graves says, “ It is probable
that this case would have terminated favourably had not extensive
gangrene of the sacrum taken place, to which the nurse did not
direct my attention, until it was of an alarming extent. It was
first pointed out to me on the eighteenth day, at which time he
laboured under hoarseness and bronchitic symptoms, unattended,
however, by any difficulty of respiration. In the course of a few
days, however, dyspnoea came on ; the wheezing in his chest
increased, and seemed to accelerate the period of death, which
appeared to all those who had witnessed the progress of the case,
to be the result of constitutional prostration, induced by the
external gangrene. On dissection, two large and two smaller
gangrenous sloughs were detected in the right lung. The gan-
grenous portions of the pulmonary tissue were insulated, being
separated from the surrounding substance of the lung by a whitish
membrane apparently formed of coagulated lymph. The question
here occurs, whether these internal gangrenes were a consequence
of the external one, or whether they were the result of the same
fatal constitutional derangement that predisposed the external
parts to become gangrenous from pressure ? The former sup-
position seems the most probable, at the same time we must
admit that gangrene often takes place in fever in external parts
not liable to pressure, as, for instance, the soles of the feet. It is
to be observed, however, that I never knew such parts to become
gangrenous, except after some other portions of the integument
had mortified, evidently in consequence of pressure.” (Clinical
Medicine, p. 781.)
In the case I have before given, there can be no doubt that the
gangrene of the liver and lungs was caused by the gangrene of
the toes. There was no other influence acting to produce it.
M. Dance published a case in many respects similar, where
gangrene of the spleen was consequent on gangrene of the
uterus.
In another chapter I shall relate a case sent me by Dr. Inman,
of Liverpool, and interesting on several accounts, in which gan-
grene of the lung was consequent on gangrenous sloughing of the
tagina.
Cruveilhier (liv. xxxvii. pi. 2, p. 3) has given a case where
104
GANGRENE OF THE LIVER.
gangrene of the gums and cheek AAras consequent on gangrene of
the uterus from cancer.
I might, if it Avere needful, adduce many other instances,
showing that gangrene of one part produced by some cause acting
only on that part, has a tendency to cause gangrene in other
parts remote from it and not subject to the same influence. It is
in this way, in effect of gangrene of some other part, that true
gangrene of the liver is most frequently produced. Rokitansky
states that he has several times observed gangrene of the liver, in
connexion with gangrene of the lung ; and has never found it
without gangrene of some other part.
105
Sect. III. — Adhesive inflammation of the capsule and of the
substance of the Liver — Cirrhosis — Other forms of inflamma-
tion of the substance of the liver.
Adhesive inflammation, — that is, inflammation which causes
effusion of coagulable lymph, — may, as wre have seen, he set
up around an abscess in the liver. When the process of suppu-
ration is over, the pus collected into a cavity, becomes bounded
by a layer of soft albuminous matter. Around this, again, coagu-
lable lymph is effused, which becoming organised, and growing
firmer, forms a cyst for the matter. 1 have already shown that the
texture of the cyst varies chiefly with the date of the abscess, and
with its size. In small, and in recently formed abscesses, the walls
of the cyst are soft and thin ; whereas, in large abscesses of long
standing, the matter is usually bounded by a substance three or
four lines in thickness, having the look and the toughness of
cartilage.
The adhesive inflammation is here limited to the immediate
vicinity of the abscess, because it is excited by the abscess, and
because the lymph poured out there cannot he diffused through the
substance of the organ.
When the abscess is near the surface of the liver, it sometimes
sets up adhesive inflammation of the peritoneum covering it, and
lymph is poured out, which unites the peritoneum above the
abscess, to the parts — the diaphragm, the abdominal parietes, the
stomach, the colon, — with which it happens to be in contact.
The adhesions thus formed are often of very small extent. The
wall of an abscess on the convex surface of the liver, may adhere
to the diaphragm or to the abdominal parietes in a space no
larger than a shilling. From this and other circumstances, many
writers have inferred that the peritoneum is less liable to adhe-
sive inflammation than the pleura. But such does not seem to
be the case. The adhesion is limited, because the irritation that
10G
ADHESIVE INFLAMMATION OF THE LIVER.
excites it is limited, and because the matter poured out does not
become diffused over the surface of the membrane.
Under similar circumstances, adhesions of the pleura may
he of equally small extent. In a case in which an abscess of the
liver discharged through the lung, I found the lung united to the
portion of diaphragm covering the abscess, in a space not larger
than a shilling.
Where small circumscribed abscesses form in the lungs from
contamination of the blood by pus, the lungs are now and then
found united to the pleura costalis in a great number of points,
corresponding to superficial abscesses, without any diffuse inflam-
mation of the pleura. The inflammation of the pleura is con-
fined to those points, because it is excited by the abscesses. In
the same way, adhesive inflammation of the pleura, from the pre-
sence of tubercles, is often of very small extent.
When lymph is effused in greater quantity on the surface of
the liver, it causes adhesion of greater extent ; and if any of the
lymph fall down among the intestines, it will glue adjacent folds
of the intestine together.
When abscess excites adhesive inflammation of the substance
of the liver, the lymph can never he diffused in this way. It all
remains, where first deposited, immediately around the abscess, and
forms a cyst for the matter.
An hydatid tumor in the liver, like an abscess, may excite ad-
hesive inflammation in the substance of the liver about it, or on
tbe capsule and peritoneum above it ; but it does not always do
so, and in consequence, an hydatid cyst, like an abscess, may
burst into the cavity of the peritoneum.
Adhesive inflammation of the surface of the liver now and
then occurs also over cancerous tumors. The lymph effused in
such cases is usually in small quantity and transparent, and the
false membranes found uniting the liver to the diaphragm and
the adjacent organs, are, in consequence, very white, and thin, and
filmy — passing merely from the summits of some of the pro-
minent cancerous masses to the opposite surface of the peri-
toneum. But, over cancerous tumors on the liver, inflammation,
even to this extent, is the exception and not the rule. Can-
cerous tumors seem never to cause effusion of fibrine in the
substance of the liver, and consequent induration ; and the liver
VARIETIES.
107
may be enormously enlarged and much deformed by them, without
any inflammation of its capsule.
Small miliary tubercles are occasionally found in great numbers
in the livers of persons dead of phthisis. I have never met with
an instance in which they seemed to have caused adhesive inflam-
mation, either of the substance of the liver or of its capsule.
In the livers of monkeys, dead of phthisis, masses of white tuber-
culous matter as large as a small bean, are often met with ; and
not unfrequently, as in cancer in the human subject, some thread-
like false membranes pass from some of the superficial tumors to
the opposite surface of the peritoneum.
Adhesive inflammation of the capsule of the liver of much
greater extent than that set up by the local causes that have been
just mentioned, occurs very frequently in this country, among the
lower orders in our large towns, in conjunction with deep-seated
adhesive inflammation of the liver, especially where this involves,
chiefly, the areolar tissue in the large portal canals.
Deep-seated adhesive inflammation of the liver produces dif-
ferent effects, according to the parts it principally involves. Some-
times the lymph is effused almost exclusively into the areolar tissue
in the portal canals of considerable size, and if the person die
long after this has occurred, all the considerable branches of the
portal vein are found surrounded, in some places to a distance
perhaps of half an inch, by new fibrous tissue, which by its con-
traction has drawn in and puckered the adjacent portions of
liver. The remaining portions of liver may be little, if at all,
altered in texture, and may be readily scraped away from these
indurated portions. The main branches of the vein are pervious,
but many of the small twigs that spring from them are obliterated.
The parts which these twigs supplied are atrophied, and the
liver proportionally reduced in bulk. Where such portions are
near the surface, the capsule is somewhat drawn in and puckered.
Together with these changes, there are usually, if not always, thick
false membranes on the capsule of the liver, or extensive adhe-
sions, by means of old tissue, between the liver and adjacent
organs. Usually, too, there are old false membranes on the sur-
face of the spleen, and marks of adhesive inflammation of other
parts, especially the pericardium and the pleura.
10
108
ADHESIVE INFLAMMATION OF THE LIVER.
I have several times met with this form of disease in persons
who had drunk hard of spirits. It comes on with well-marked
symptoms of inflammation of the liver, — pain in the side, vomit-
ing, fever, and perhaps jaundice. These symptoms subside after
a time, but the patient does not regain his former health. The
liver has been permanently damaged ; part of its secreting sub-
stance becomes atrophied from closure of the small portal veins,
and it is no longer adequate to its office. The patient has difficult
digestion, looks sallow, and does not recover his former strength.
In other cases of deep-seated adhesive inflammation of the
liver, the lymph is not effused solely, or chiefly, iD the large
portal canals. We do not find the fibrous tissue about the large
branches of the portal vein especially, hut about the small twigs
that separate the lobules. All the substance of the liver is ren-
dered tough by this new fibrous tissue, which, when the liver is
sliced, is seen to form thin lines between small irregular masses of
lobules. At the parts on the surface of the liver which correspond
to these hues, the capsule is drawn in, so that the surface has
a “ hob-nailed ” appearance.
The tissue of the liver is paler than natural, from the presence
of this white fibrous tissue, and from its containing hut a small
quantity of blood ; and it is often yellowish from accumulation
of biliary matter in the cells. When this is the case, a section
has the greyish and yellow colour of impure hees-wax, and,
in consequence, the disease has been called by the French,
cirrhosis.
In other cases again, the quantity of this adventitious fibrous
tissue is much greater, and by its contraction the lobular substance
of the liver is drawn into itrand nodules, which being of a deep
yellow colour from accumulation of biliary matter, are in strong
contrast with the grey fibrous tissue between them.
This state has been described by Abercrombie, wrho says, the
yellow matter of cirrhosis is sometimes in small nodules, like
peas, dispersed through the substance of the liver. He adds, “ A
case is described by Clossy, in which the structure of the liver
was wholly constituted of a congeries of little firm globules, like
the vitellarium of a laying hen ; it occurred in a hoy of fifteen,
who had immense ascites. In a case by Boisment, these nodules
were as large as peas, and the liver was much diminished in size ;
the case was chronic with ascites. The French writers have a
CIRRHOSIS.
109
controversy whether the cirrhosis or yellow degeneration of the
liver, he a new formation, or a hypertropliia of the yellow sub-
stance, which they suppose to constitute a part of the structure
of the liver in its healthy state. No good can arise from such
discussions, as it is impossible to decide them.” (Diseases of the
Stomach, &c., 2nd edition, p. 3G9.)
The disease is seldom met with in this degree, but I have lately
seen an instance of it, in the person of a man who died under
my care in King’s College Hospital. An account of his case, which
I subjoin, will probably not be uninteresting.
Case. — Spirit-drinking — Jaundice — Vomiting of blood — Ascites and oedema of
the legs — Extreme degree of Cirrhosis.
Gilbert Campbell, act. 40, was admitted into King’s College Hospital,
the 16th of June, 1843. At the age of 30, be became a commercial tra-
veller, and continued so seven years, during which he drank hard of wine
and spirits. The last three years, had been a commission-agent, and had
drunk much less, his chief beverage being ale.
He had very good health till he became a commercial traveller, but from
that time had frequently pain in the stomach and vomiting, after excess in
drinking. In the month of February, 1841, when travelling to Birmingham,
he became jaundiced. Tire jaundice went off in about a fortnight, and after
that he had no particular ailment, till the summer of 1842, when he was laid
up two or three weeks with gout in the left foot. This was his first attack
of gout, and he has had no return of it since. In addition to these ailments
had for several years suffered from stricture of the urethra, and from a
winter cough, attended with expectoration. Lately, has had occasional
bleeding from the nose.
He followed his usual occupations till three weeks before his admission to
the hospital, when he was taken in the street with vomiting of blood. The
vomiting recurred several times during the day ; he thinks he brought up, in
all, as much as four quarts of blood, and was very faint in consequence.
Two days after, he noticed that his belly was swelled, and in a day or two
more, he had also swelling of the ankles.
When he came into the hospital, he had a sallow, cachectic look, his con-
junctivae were yellowish, his skin hot and dry, his mouth parched, his lips
chapped and bleeding. His legs and thighs were very oedematous, but there
was no oedema of the hands or face. The belly was much distended with
fluid, but it was not painful or tender, and his chief complaint was of a
sense of tightness across the loins. The cutaneous veins of the belly were
not enlarged.
Pulse 100, regular, tolerably full.
Respiration, twenty a minute. He had some cough ; and spat up viscid
no
ADHESIVE INFLAMMATION OF THE LIVER.
mucus. No pain of the chest. A soft systolic bellows sound was heard at
the base of the heart, and along the arteries.
The urine was of natural colour, clear, of sp. gr. 1015, free from albumen.
His intellect and his senses were unimpaired, and he slept well.
The day after, he complained more of the feeling of tightness across the
loins, and as he had passed but little water, the physician’s assistant imagined
the bladder was distended. A catheter was introduced in consequence,
but only a small quantity of urine was drawn off. The operation was very
difficult, on account of the stricture, which was found to be a close one. It
was followed by considerable bleeding from the urethra ; and for three or four
days afterwards, some blood came away before the urine each time he
passed it.
From this time to the 26th of August, no striking change took place.
The pulse ranged from 96 to 114. The appetite was uncertain and the
bowels were irregular. He vomited the day after the catheter was passed,
but at no other time. He had now and then some bleeding from the nose
and from the gums. His skin was hotter than natural, and his tongue was
generally dry and somewhat glazed, but he did not complain much of
thirst. The urine was always clear, and free from albumen, and its sp gr.
ranged from 1015 to 1022. He had throughout the same sallow, cachectic
look as at first.
At the end of this time, the cutaneous veins of the abdomen had become
much enlarged, and the ascites, which had been gradually increasing, was
enormous. The legs too, were enormously swelled, and the scrotum and
penis were very cedematous. He complained much of the sense of distension
and of pain in the loins. The belly was then tapped, and twelve pints of
serous fluid were drawn off.
The fluid had a sp. gr. 1013; and according to my friend. Dr. Miller, who
made an analysis of it, was composed of : —
Water ----- 968-95
Albumen ----- 22-51
Salts and extractive matter - - 8"54
1000
It contained phosphates of lime and magnesia ; chlorides of potassium and
sodium ; sulphate of potash, and free soda ; a trace of iron, and a trace of
silica, but not a trace of urea.
After the tapping, he was for some time much more comfortable, but the
ascites came on again; and by the ISth of September, had reached its
former degree. He suffered much from the great cedema of the penis and
scrotum, and to relieve this some punctures were then made in the legs.
The discharge from the punctures was very profuse, and the cedema of the
scrotum and of the legs diminished. The skin about the punctures in the
left leg became red and painful, symptoms of sinking came on, and he died
on the 26th.
On his admission to the hospital, he was put on milk diet, which with a
few extras, was his diet throughout, and he was ordered a saline draught with
CIRRHOSIS.
ill
nitre and hyoscyamus. On the 21st of June, he was given, in addition, two
grains of calomel with a quarter of a grain of opium, three times a day, till
the 26th of June, when, the mouth being sore, the calomel was ordered to
be taken only occasionally. The mouth was kept sore till the 3rd of July,
without any benefit. The medicines he had been taking were then left oft,
and he was ordered instead, to take a diuretic draught, containing three
grains of iodide of potassium, three times a day, and to rub in over the liver
some compound iodine ointment every night.
This treatment was continued till the beginning of August, without pro-
ducing any appreciable change in his condition. It was then left off, and
afterwards he took only a simple diuretic mixture, with a saline purgative
now and then, when the bowels were confined or when he felt unusual dis-
tension.
The body was examined thirteen hours after death.
The legs were very cedematous, and on the skin about the punctures in
the left leg, were some vesication s, as if from commencing gangrene. There
was no oedema of the hands or face.
The abdomen contained a large quantity of straw- coloured, serous fluid.
The liver was small, and weighed only two pounds and eleven and a half
ounces. Its under surface was whitened by a very thin false membrane, and
its upper surface had an opaline tint, apparently from an extremely thin false
membrane extended over it. It was united to the diaphragm by a few threads
of false membrane near the suspensory ligament, but had no other unnatural
adhesions. Its edges were rounded, and its surface was roughened by the
projection of small, round nodules. When sliced, it was found to be
generally pale, from containing but little blood, and the cut surface had a
mottled appearance from being thickly studded with roundish bodies, varying
in size from the smallest perceptible to that of a small pea, and contrasting in
colour with the intervening substance— the colour of the round bodies or no-
dules, being yellow in various shades, from pale yellow to brown ; that of the
intermediate substance being pale without any yellow tint. The rounded
bodies were pretty uniformly distributed throughout the substance of the
liver. They were not generally larger or more numerous deep in its sub-
stance than near the surface.
The matter of these round yellow nodules, examined under the microscope,
showed a mass of the nucleated cells of the liver tinged yellow. Some cells
were yellow throughout ; in others, there was a spot of yellow about the
nucleus, or rather about the centre of the cell, while the portion near the
circumference had its usual appearance. The quantity of yellow matter in
the cells was greater, the deeper the colour of the nodule from which they
were taken. Some cells from the lighter coloured nodules, or from the sub-
stance about them, had no yellow tint, and were perfectly natural. Some
cells contained a good deal of oil, in globules, which was very unevenly
distributed ; the cells in some portions containing little, in others much.
The grey substance intermediate to the nodules was tough, and seemed a
modification of white fibrous tissue. It was opaque, and had a confused
112
ADHESIVE INFLAMMATION OF THE LIVER.
granular appearance under the microscope. When a drop of acetic acid was
placed on the specimen under the microscope, it became much more trans-
parent, and exhibited a great number of distinct granules.
The gall-bladder and ducts, as far as they could be readily traced, and the
portal veins, seemed quite healthy.
The gall-bladder contained olive-coloured bile, so viscid that it could be
drawn out in threads.
The spleen was rather large, and its surface was mottled with white, by
a very thin coating of contracted lymph. Its substance was tolerably firm,
and of its natural colour.
There were no marks of inflammation of the peritoneum investing the
stomach and intestines. The mucous membrane of the stomach was
healthy, and nowhere softened. There was some thickening and indura-
tion of the submucous areolar tissue, forming a ring, not above two lines in
breadth, about the pylorus. No thickening of the areolar tissue in other parts
of the stomach.
The coats of the intestines were pale, and those of the small intestine were
thin ; but the mucous membrane was healthy throughout.
The ascending and the transverse portions of the large intestine were much
distended with gas.
The kidneys were quite healthy.
The cavity of the left pleura contained a considerable quantity of serous
fluid, and on the lower lobe of the left lung, and the corresponding part of
the pleura costalis, there was a thin coating of recently effused lymph. The
lower lobe of the lung was compressed by the liquid, but the lung was other-
wise healthy. The right lung was united to the pleura costalis, by a few
threads of old false membrane, but presented no other marks of disease.
The heart was small, and the pericardium and valves were quite healthy.
The aorta was healthy.
The brain was not examined.
The right branch of the portal vein was injected for me by my colleague,
Mr. Simon. The size did not flow freely, and the left lobe of the liver was
not at all coloured by it. The larger of the nodules in the right lobe were
however coloured by the size, and under the microscope the capillary vessels
in their interior were seen to be injected.
I could not discover that any portal veins were obliterated. Perhaps they
were merely compressed by the new tissue.
In this case the appearance of the liver corresponded exactly to
the description given hy Abercrombie of one form of cirrhosis,
where the yellow matter is dispersed through the substance of the
liver, in small nodules like peas ; or, to take the comparison of
Glossy, as in the vitellarium of a laying hen.
An examination through the microscope showed at once, that
this yellow matter was the original lobular substance of the
CIRRHOSIS.
1 13
liver, which was drawn into these round nodules by the adventi-
tious tissue between them.
The nodules were empty of blood and tinged with bile from the
impediment the new tissue caused to the entrance of blood by the
portal veins, and to the escape of the bile through the ducts. The
adventitious tissue was formed, no doubt, from coagulable lymph.
It had much the appearance of false membrane at an early stage
of organization.
The small size and weight of the liver, notwithstanding this
new tissue, shows to what an extent the original lobular sub-
stance of the liver had shrunk. Enough of it was, however, left,
living as the patient did, to prevent the occurrence of decided
jaundice.
The ordinary appearances in cirrhosis, and the changes just
described, seem the consequence of adhesive inflammation in the
areolar tissue about the small twigs of the portal vein, by which
serum and coagulable lymph are poured out. The serous part of
the effusion gets absorbed, and the fib l ine contracts and becomes
converted into dense fibrous tissue, which divides the lobular sub-
stance of the liver into well-defined masses, gives great density
and toughness to the organ, and by compressing the small twigs
of the portal vein and the small gall-ducts, and thus impeding the
flow of blood and the escape of bile, causes the pale yellowish
colour of the masses of lobules.
In the chapter on suppurative inflammation of the substance of
the fiver, it was remarked, that where the inflammation results
from contamination of the portal blood, the capsule of the fiver,
and the peritoneum covering it, are often exempt from disease ;
that it is only when the abscess approaches the surface that adhe-
sions form between the fiver and adjacent organs; and that even
in such cases the adhesions are often of small extent, being limited
to the portion of peritoneum covering the abscess.
In adhesive inflammation of the fiver brought on by spirit-
drinking, the physical cause of the inflammation is likewise
brought by the portal blood, and the capsule is not primarily
affected. In some cases even of hob-nail fiver, the peritoneum
covering the fiver presents no trace of disease, and the capsule has
its natural appearance, and can be readily stripped off. In other
cases, the capsule is hard to remove ; and frequently, there is an
i
114
ADHESIVE INFLAMMATION OF THE LIVER.
extensive false membrane on the surface of the liver, or there are
tufts of newly-formed tissue uniting the liver to adjacent organs.
In the form of disease before described, where the newly-formed
fibrous tissue is found in great quantity, but solely or chiefly in
the portal canals of considerable size, false membranes on the
surface of the liver are perhaps constant, and are certainly in most
cases much thicker than in ordinary hob-nailed, or granular, liver,
where the new fibrous tissue is more interstitial.
In the early stage of cirrhosis, the liver is much enlarged by
the serum and lymph effused within it. In time, the watery part
of the effusion is absorbed, the fibrine contracts, the small twigs
of the portal veins ore compressed by the new tissue, and the
lobular substance of the liver, receiving less blood than it should do,
wastes. On all these accounts the liver diminishes in size, and in
protracted oases, from the small quantity of blood it contains,
and the great atrophy of the lobular substance, it is usually very
much smaller than in health.
Dr. Bright says that in some cases he has been able to follow,
distinctly, the enlargement of the liver early in the disease, and its
gradual diminution afterwards. On account of the slowness of
the change, and the difficulty of ascertaining the exact size of the
liver, we can seldom obtain this direct evidence of its shrinking.
But if adhesions have formed between the liver and adjacent
organs, we may frequently assure ourselves that the liver has
greatly shrunk, by simply inspecting the bands of adhesion.
Some time ago, in a case of advanced cirrhosis, I found a band
of cellular tissue some inches in length, uniting the liver to the
spleen. The adhesions must have formed when the organs were in
contact, and have been drawn out as one or the other contracted.
In another case of advanced cirrhosis, I found the convex sur-
face of the liver united to the diaphragm by tufts, or bands of
false membrane, an inch in length. The parts of the liver at
which these tufts were inserted, were hollow or depressed, and
when all the tufts were divided, the surface of the liver was very
uneven.
Here, as in the case in which the liver and spleen were united,
the adhesions must have formed when the surfaces were in contact,
and the bands have been drawn out as the surfaces receded from
each other. In both cases, these tufts or bands were evidence of
the contraction of the liver, after adhesions bad formed. The de-
CIRRHOSIS.
115
grec of contraction being different in different parts, the surface
of the liver becomes uneven.
The small gall-ducts, like the branches of the portal vein they
accompany, are compressed, and perhaps sometimes completely
obstructed by the new fibrous tissue ; but the mucous membrane
of the gall-bladder and larger ducts, is generally healthy. The
outer coats of the gall-bladder are sometimes found thickened, and
the gall-bladder contracted, from the deposition of fibrine, which
has subsequently become organised or contracted ; but this
change, like the adhesions of the capsule of the liver, which are
generally found along with it, seems to be secondary ; — the
consequence of inflammation propagated from the deep-seated
tissues.
If the inflammation of the capsule be extensive, and much
lymph be poured out, some of this may fall among the intestines,
and cause adhesion of contiguous folds.
The coagulable lymph poured out in inflammation of a serous
membrane seems to cause adhesive inflammation and effusion of
lymph of the same kind, from every part of the membrane to
which it may be mechanically transferred. In this way, perhaps,
cirrhosis may lead to adhesive inflammation of the entire surface
of the peritoneum,
In persons who have died of ascites, apparently the result of
cirrhosis, the entire surface of the peritoneum investing the liver
and intestines, has now and then been found covered by a dense
false membrane. I have met with one instance of this kind, and
some others are recorded by Dr. Bright in his Hospital Reports.
It is possible that in some such cases, adhesive inflammation of
the peritoneum was the primary disease; and that the dimi-
nished size and increased firmness of the liver, and obstruction to
the circulation through it, were caused by tho contraction of the
dense false membrane that covered it.
The bile found in the gall-bladder in persons dead of cirrhosis,
presents various appearances. Often, it is thin or serous, and of
an apricot or orange colour (Andral, obs. 21); in other cases,
where the change in the texture of the liver seems just the same,
it has its natural appearance (Andral, obs. 18). Sometimes, it is
black and thick.
In consequence of the impediment to the passage of the portal
blood through the liver, the intestinal veins which feed the vena
11G
ADHESIVE INFLAMMATION OF THE LIVER.
portse are found distended, and when there is no false membrane
on the peritoneum, the capillary veins in those parts of the perito-
neum to which the blood gravitates, are seen beautifully injected
and varicose. It now and then happens in such cases that the
coats of the intestine are oedematous ; and in a case related by An-
dral, there was oedema of the coats of the gall-bladder. In a sub-
ject examined by Carswell, the trunks and branches of the portal
vein were found blocked up by fibrinous coagula. The condition
of the fiver is described by Carswell, and represented in (plate 2,
fasc. “ Atrophy”) his work on morbid anatomy.
With such evidence of impediment to the passage of the portal
blood through the fiver, we might expect that the spleen would
always, or generally, he congested and enlarged, in cirrhosis. But
it is not found to be so. The appearance of the spleen does not
indeed seem to be much modified by the existence of cirrhosis. It
may he of natural size and appearance (Andral, t. iv. ohs 18) ;
or small and soft (lb. ohs. 17) ; or small and firm. (Ib. obs. 19.)
How is this to he accounted for ?
Morbid changes are often found in other organs in persons
dead of cirrhosis, the consequence of the habits of fife that pro-
duced the cirrhosis, or of other morbific causes ; hut no such
changes have been observed so constantly as to lead us to consider
them essential, or entitled to be specified in a general description
of the disease.
Causes. There are perhaps various conditions capable of pro-
ducing, or that may help to produce, the different forms of ad-
hesive inflammation of the substance of the fiver under con-
sideration, but the most common and most powerful cause in
this country, indeed the only cause whose influence is apparent, is
spirit- drinking. These forms of disease are in consequence most
frequent in large manufacturing towns, among the poorer classes,
many of whom spend great part of their earnings in gin ; and
for this reason the granular and the hob-nail fiver, known to the
French as cirrhosis, has been familiarly termed by English prac-
titioners, the gin-drinkers' fiver.
The influence of spirit- drinking in producing this disease has
also been observed in France. Andral states that in most of the
cases of cirrhosis he has recorded, the patients had drunk spirits to
excess. He imagines that the spirit may produce irritation of the
CIRRHOSIS.
117
mucous membrane of the intestinal canal, which may spread
through continuity of tissue to the gall-ducts, and from them to
the substance of the liver ; or that the alcohol, being absorbed
into the veins, may act directly on the liver. The latter explana-
tion is, undoubtedly, the time one. The spirit is absorbed by the
blood-vessels, and being conveyed at once to the liver, exerts an
immediate action on its tissues.
Some interesting observations on the effects of poisoning by
alcohol, were published a few years ago by Dr. Percy, of Bir-
mingham, in an Essay, which obtained one of the gold medals
annually given in the university of Edinburgh. Dr. Percy found
that in dogs poisoned by alcohol, he could recover alcohol from
the blood, the brain, and various other organs, but in greatest
quantity from the liver.
The inflammation of the areolar tissue in the portal canals is
probably owing to diffusion of alcohol through it from the portal
veins. We can readily fancy such diffusion taking place, if we
consider bow volatile alcohol is, and how readily it permeates
animal membranes and tissues. These properties of alcohol also
explain the circumstances noticed by most pathologists, that in
cirrhosis the whole liver is changed in structure, and the different
parts of it generally in pretty equal degree.
If globules of mercury or of pus find their way into the veins
that feed the vena portae, they become arrested at particular points in
the lobules of the liver, and excite at each of those points circum-
scribed inflammation and abscess, while the rest of the liver may
continue healthy ; but alcohol, being volatile, and mixing readily
with water, becomes equally diffused through the whole mass of
portal blood flowing through the liver, and the inflammation it
excites involves in consequence the entire organ.
There are various circumstances that seem to favour the action
of alcohol in producing cirrhosis. One of them is obstructed
circulation through the lungs or heart. M. Becquerel, in an ela-
borate paper on cirrhosis, published in the Archives Generales, in
1840, states that the heart was diseased in twenty-one out of
forty-two cases of cirrhosis, of which be lias given an analysis ;
and that in these cases the heart was diseased before the liver.
But he also states that in thirteen of these twenty-one cases the
cirrhosis was at what he calls the first degree, and gave rise to no
symptoms, or to very trifling symptoms. It is perhaps fair to
J IS
ADHESIVE INFLAMMATION OF THE LIVER.
infer that in some of these cases, M. Becquerel mistook for the
first stage of cirrhosis the nutmeg appearance of the liver pro-
duced by partial congestion of the capillaries.
If we exclude these doubtful cases, there still remain a con-
siderable number in which some disease of the heart was found
associated with the disease of the liver, and, if we may credit M.
Becquerel, was antecedent to it. M. Becquerel, indeed, maintains
that disease of the heart, by producing long-continued congestion
of the liver, is, of itself, the most common cause of cirrhosis. But
it is far more probable that obstructed circulation through the
chest has no direct influence in causing the disease, and that it
contributes to it only by giving greater effect to the influence of
alcohol and other efficient causes. There is no reason to believe
that mere passive congestion of other organs has any direct influ-
ence in causing active inflammation of them ; and disease of the
heart would surely lead to oedema of the legs and general dropsy,
before it would cause extravasation of the fibrine of the blood into
the substance of the liver.
The frequent association of disease of the heart with this dis-
ease of the liver may be in part accounted for, from the great
prevalence of diseases of the heart, from rheumatism, and other
causes, among the lower classes in our large towns, who are the
chief victims of spirit- drinking ; and, perhaps, from this destructive
habit having a tendency to produce disease of the heart and great
vessels, as well as of the liver.
Another condition that favours the influence of alcohol in pro-
ducing cirrhosis, is a hot climate. In cold countries, people may
drink with impunity, perhaps with benefit, quantities of spirit
that would prove very injurious in hot ones. It has been re-
marked that our troops stationed in Nova Scotia and New
Brunswick, (where, from the low price of spirits, there is much in-
temperance,) suffer less from diseases of the liver than those at
home. In hot countries, hard-drinking seldom fails to bring on
disease of the liver. Baron Larrey, in his account of the health
of the troops in Napoleon’s campaign in Egypt, (tom. ii. p. 42,)
says that wine and fermented liquors produce the most baneful
effects in that country, and remarks that it is a wise law of the
Koran that forbids their use.
There are, perhaps, various other conditions that give greater
efl'ect to habits of intemperance in inducing disease of the liver.
CIRRHOSIS.
119
A congested state of the liver from whatever cause, or a feverish
state of the system, in all probability disposes to it.
The influence of fermented liquors in producing cirrhosis,
accounts for the disease being more common in men than in
women, and much more common in persons above the age of
thirty than below it.
Cirrhosis is occasionally met with in some of our domestic
animals. Dr. Carswell has given a drawing of a portion of a
cow's liver, which had the characters of this disease. The cow had
ascites. Dr. Carswell says nothing of the food ou which the
animal had been kept. I have found the same disease in the
liver of a pig.
It is also sometimes met with in temperate persons, — so that
we must admit other causes besides spirit- drinking. There may
be other substances, among the immense variety of matters taken
into the stomach, or among the products of faulty digestion,
which, on being absorbed into the portal blood, cause, like alcohol,
adhesive inflammation of the liver. As yet, however, this is only
matter of surmise.
In a considerable proportion of the published cases of cirrhosis,
there was organic disease of the stomach : and in many of those
published by Andral, — the most detailed to which I can refer, —
the illness seems to have commenced with vomiting and purging,
winch was followed, after some time, by ascites. Many cases
seem certainly to point to some product of faulty digestion, as an
immediate cause of the disease..
It is probable also, from the chief seat of the effusion, that
the disease may occur independently of any contamination of the
portal blood — and that the physical cause, if any exist, may be
conveyed through the hepatic artery.
Symptom*. — Cirrhosis usually comes on very insidiously, and
when the inflammation does not involve the capsule of the liver,
the symptoms are in most cases few and obscure, until the fibrino
effused in the substance of the liver has caused impedimeut to
the flow of the portal blood, and to the secretion and escape of
bile. Some enlargement of the liver, a dull pain in the right
hypochondrium, and disordered digestion, arc the chief symptoms
in the early stages, and some of these even may be wanting, or be
so slight as to escape our notice.
120
ADHESIVE INFLAMMATION OF THE LIVER.
In some cases, however, the onset of the disease is more
sudden, and the symptoms at first are more striking and more
indicative of active inflammation. The patient has fever, with
loss of appetite, perhaps occasional vomiting, and, it may he,
jaundice, and his urine is high-coloured and charged with lithates.
There is much pain and tenderness in the region of the liver, and
the liver is readily felt to be enlarged.
The disease begins in this way when much lymph is effused at
once, and the inflammation involves the capsule of the liver.
When the acute symptoms are subdued by treatment, or subside
of themselves, the patient follows his usual occupations, and pre-
sents only the slight tokens of disease before mentioned. But he
finds that he gradually grows weaker and thinner, his appetite is
uncertain, his skin becomes dry and rough, and Iris complexion
sallow and earthy.
After the lapse of some weeks, or months, or years, — according
to the quantity of lymph first effused, the success of the treat-
ment then adopted, and the subsequent habits of the patient — the
fibrine poured out has become so contracted, and is in such
quantity, that the free passage of the blood through the liver, and
perhaps also the free escape of bile from it, is prevented. There
then occur a different train of symptoms, which are so charac-
teristic, that there is little difficulty in detecting the disease.
The belly becomes enlarged from effusion of serous fluid into
the cavity of the peritoneum, which takes place without pain or
tenderness, and gradually increases so as to cause great distension
of the belly, and often, by impeding the movements of the dia-
phragm, much difficulty of breathing. In some cases this dropsy
of the belly is followed by oedema of the legs, but there is no
oedema of the hands or face, unless there be likewise disease of
the heart or kidneys.
The patient is liable to hemorrhage from the bowels, and to piles,
and the veins on the surface of the belly are enlarged. This
enlargement of the cutaneous veins shows clearly that the current
of the portal blood is impeded, and is very characteristic of the
disease we are considering.
The complexion is sallow and earthy, or of a slightly greenish
cast, and the skin is almost invariably dry and rough.
The appetite is uncertain, often entirely gone ; the skin is hotter
than it should be ; the patient has occasional thirst; the tongue is
CIRRHOSIS.
121
slightly furred ; the lips are frequently redder than natural, and
contrast strongly with the pale and sallow face ; digestion is
painful or disordered, often with heartburn and sour eructations ;
and the urine is almost always scanty and high-coloured, and
generally throws down a deep-red, sometimes a pinkish sediment
of lithate of ammonia.
There is likewise tendency to hemorrhage from the nose and
other parts in which there is no particular stress on the vessels.
Small purpuric spots often appear on the face or forehead, sometimes
on the distended belly ; and if the patient he cupped, eccliymosis is
apt to take place about the punctures.
When ascites has once occurred, it persists ; the patient con-
tinues to lose flesh and strength, and after the lapse of some
months, or perhaps a year or two, dies, usually from gradually
increasing exhaustion.
In some cases, when the patient is much reduced, death is has-
tened by the occurrence of colliquative diarrhoea, or by the drain
from the system caused by tapping, to which recourse is had to
relieve the distress of breathing or the other evils which the great
distension of the belly occasions.
The intellect and senses are usually free from disorder to the
last.
It will readily he seen, that most of the symptoms of the
advanced stage of cirrhosis result from obliteration or compres-
sion of the small twigs of the portal vein, and the consequent ob-
stacle to the circulation through the liver. The blood in the
portal vein cannot pass through the liver with its usual freedom,
the veins that go to form the portal vein become, in consequence,
distended, and various effects follow,
1st. — The most striking, perhaps, of these is ascites , or dropsy
of the belly, which is an immediate effect of the distension of the
veins that return the blood from the peritoneum. In conse-
quence of this distension, the serous part of the blood transudes
through the vessels, or absorption by those vessels is less active
than it should he, and serous fluid — of much less density, however,
and containing much less albumen, than the serum of the blood —
collects in the cavity of the peritoneum.
Ascites constantly exists in the advanced stages of cirrhosis,
and is the more important as a distinguishing sign of this disease.
122 ADHESIVE INFLAMMATION OF THE LIVER.
because it occurs in few other diseases of the liver. In abscess of
the liver, in hydatids of the liver, in the fatty liver, in diseases of
the gall-bladder and ducts, the course of the blood is not im-
peded, or is not impeded in such a degree as to cause ascites. As-
cites is, however, not unfrequently produced by cancerous masses
in the liver, but here the dropsy seldom attains the degree that it
does in cirrhosis. It may, likewise, be produced by obliteration
of the branches of the portal vein, which we find now and then
as the only morbid change in the liver — very seldom, however, to
such extent as to produce this effect. Ascites occurs also in
what has been termed scrofulous disease of the liver, but this
disease also, at least in the degree requisite to produce dropsy, is
very rare. So that, in most of the cases in which considerable
dropsy of the belly depends on the liver, it depends on cirrhosis.
The dropsy in many cases is confined to the belly, which may
be enormously distended with fluid, while there is no rndema
whatever of the face or arms, or even of the legs. Frequently,
however, together with ascites, there is oedema of the legs, but
unless there be some disease of the heart, or of the kidneys, the
oedema of the legs is always consecutive to the ascites. This
may readily be explained. An obstacle to the flow of blood
through the liver acts at first almost exclusively on the portal
system. It has no direct effect on the general circulation, except
through the anastomoses between the hemorrhoidal veins and the
branches of the internal iliac vein. It causes, therefore, little
direct impediment to the return of blood from the legs. The
oedema of the legs, observed in some cases of cirrhosis, not only
comes on after the ascites, but most probably is caused by it, and
is the effect of compression of the vena cava and of the iliac veins
by the fluid distending the peritoneal sac.
Another effect of permanent obstruction to the flow of blood
through the fiver, is a constantly congested state of all the vessels
of the intestines, which often gives rise to piles, and not unfre-
quently to discharges of blood from the stomach or bowels.
The blood, thus impeded in its course through the fiver, finds
another passage to the heart through the cutaneous veins, chiefly
by means of the anastomoses between the hemorrhoidal branches
of the inferior mesenteric vein and branches of the internal iliac
vein.
CIRRHOSIS.
123
When adhesions form between the surface of the liver and the
abdominal parietes, they become organized and traversed by
numerous vessels, which can be readily injected from the hepatic
artery,* and which establish additional channels between the cap-
sular branches of the portal vein, and the superficial veins of the
trunk.
It is very common in cases of advanced cirrhosis, to see large
cutaneous veins on each side of the belly and chest. Gene-
rally they are most marked on the right side, and become larger
at the hypochondrium, but can be traced from the flank. More
than once, however, I have seen a large vein emerge, abruptly,
immediately below the right false ribs, and pass up over the chest
in a varicose condition.
Blood likewise finds its way to the heart circuitously by means
of anastomoses between the capsular branches of the portal vein,
and branches of the phrenic vein. These indirect channels are
also often increased in number by means of adhesions between
the fiver and the diaphragm. Such adhesions, then, so far an-
swer a good purpose, that they favour the return of blood to the
heart, and lessen the distension of the portal veins.
The constant state of distension of the vessels of the stomach
and intestines, of course retards the absorption of liquids by those
vessels, and may perhaps serve to explain in part, the dryness and
roughness of the skin so generally observed in cirrhosis, the occa-
sional thirst even when there is no fever, and the scanty, high-
coloured, and heavy urine. Since many of the soluble elements
of food enter the blood through these veins, their permanent
distension will also account in part for the loss of flesh and
strength.
The distension of the vessels of the intestines does not cause a
How of serum from the mucous membrane, nor, it would seem, any
increased secretion from it. The bowels are not unfrequently
confined in confirmed stages of the disease. The elements of the
blood do not escape from mucous , or from synovial membranes,
from mere passive distension of tbc blood-vessels. The catarrh
which is so constant where the bronchial membrane is congested
from obstacle to tbe circulation through the left side of the heart,
depends probably, not on the mere passive congestion, but on the
consequent chemical action of the air on the tissues.
* Kiernan. Phil. Trans. 1833.
124
ADHESIVE INFLAMMATION OF THE LIVER.
The obstructed circulation through the liver sei*ves also to ex-
plain in part, the sallow, dingy complexion, so constantly ob-
served in advanced stages of cirrhosis. Part of the portal blood,
instead of traversing the liver, finds another way, through the
abdominal parietes, to the heart. This part of the blood cannot he
purified, or freed from the constituents of bile, as it should he, and
must consequently contaminate the whole mass of blood with
which it is mixed. In this respect, cirrhosis offers an analogy
to those cases in which there is a mixture of venous and arterial
blood, in consequence of communication between the two sides of
the heart.
The circumstance, that all the portal blood does not pass
through the liver, may thus account in part for the peculiar cast
of complexion ; but in most cases, no doubt, the blood that does
pass through the liver is very imperfectly purified, and still retains
after its passage some of the principles that should have been
eliminated as bile. We have seen that the lobular substance of the
liver which serves to secrete the bile, is much diminished in bulk,
and that what is left of it is often in a state of biliary congestion,
probably from impediment to the free escape of bile through the
small ducts. The damage thus done to the nucleated cells, the
agents of secretion, of course renders the secretion imperfect. The
bile found in the gall-bladder after death has often a pale orange
or straw-colour, instead of its natural tint.
A sallow, jaundiced complexion is much more constant in cir-
rhosis than in abscess of the liver, because in cirrhosis the entire
mass of the liver is altered in structure, and the function of every
part of it is more or less impaired, whereas suppurative inflamma-
tion is generally partial, and not unfrequently a portion of the
liver adequate to the ordinary purpose of secretion remains healthy.
In cirrhosis, the secretion of bile is never, or is very seldom,
completely arrested. There is seldom decided jaundice, and, even
in advanced stages of the disease, the discharges from the bowels
are coloured by bile.
The change in the complexion takes place gradually, as the con-
traction of the effused fibrine impedes more and more the secretion
and the flow of bile.
Dr. Bright, speaking of such cases, says, “ The change from the
natural colour is usually gradual ; and the yellow tinge of the
conjunctiva often precedes for some weeks any more decided in-
CIRRHOSIS.
125
dication. In time, however, the bronzed appearance of the fore-
head, or the darkened areola of the eye, bespeak the approaching
change; and a jaundice, bearing the lighter tints, from a sallow
suffusion to a fainter or more decided lemon hue — still, however,
liable to considerable fluctuation, establishes itself over the whole
body.”
The sallow cast of the complexion in the advanced stage of cir-
rhosis, depends, like the ascites, on an organic change in the
texture of the liver, which does not admit of remedy. When the
effused fibrine has become organized,, it forms part of the living
tissues, and is incapable of removal. The sallowness, then, like
the ascites, although it may vary somewhat in degree, never dis-
appears when it has once come on at this stage of the disease.
When observing the complexion, we must not be misled by the
permanent bronzed appearance of the face, so common in persons
who have been much in hot climates, which is produced by mere
exposure to the sun, without any disease of the liver. In such per-
sons the skin of the chest and parts covered by clothing, have their
natural healthy tint.
We must also take care not to be misled by the sallowness of the
face that results from mere deficiency of red globules in the blood.
Such cases are readily distinguished by tlae circumstance that the
conjunctiva is of a bluish-white and pearly, while in the sallow-
ness that results from deficient secretion of bile, the conjunctiva
is more decidedly yellow than the skin.
The emaciation and the loss of strength — other constant symp-
toms in cirrhosis — depend perhaps in part on impairment of
all the assimilating functions, by the habits of life that induce
cirrhosis; but they are no doubt mainly owing to the obstructed
circulation through the liver, and the imperfect secretion of bile.
The obstructed circulation impedes, as we have seen, the ab-
sorption of water, and also of other substances that contribute to
nutrition, by the veins of the stomach and intestines. Imperfect
secretion of bile tends to impair nutrition in two ways. The bile,
which no doubt performs an important part in digestion, flows in too
small quantity into the duodenum, and digestion is in consequence
imperfectly performed ; and, on the other hand, some of the prin-
ciples which should be eliminated as bile, remain in and conta-
126
ADHESIVE INFLAMMATION OF THE LIVER.
ruinate the blood ; causing languor and drowsiness, and weakening
in some degree all the assimilating functions.
The loss of flesh and strength, then, like the ascites and sallow
complexion, depends in great measure on changes of structure
which we cannot remedy, and although it may be hastened by
lowering treatment, or other causes, and may be in some degree
stayed by judicious measures, is, of necessity, when the disease
has attained a certain degree, constantly, though slowly, pro-
gressive.
Diagnosis. — In the early stage of cirrhosis, the symptoms are
often few, and present no distinctive, and, to common eyes, no
alarming, characters — so that it is only by considering the circum-
stances in which they arise that we are led to perceive their true
significance. Slight sallowness of complexion, a dull pain or
some degree of tenderness in the right hypochondrium, with occa-
sional feverishness, in a person above the age of thirty, who has
been long in the habit of drinking spirits to excess, are almost con-
clusive evidence of the existence of cirrhosis, even before there is
any direct proof that the circulation through the liver is impeded.
The symptoms, in themselves, may be slight, but knowledge of
the habits of the patient enables us to regard them as tokens
of organic and incurable disease. Here, as in so many other
cases, it is only by knowing the causes of the disease, or the cir-
cumstances under which it usually occurs, that we become watch-
ful of its earliest tokens, and perceive, as it were, the shadows that,
in coming, it casts before it.
When by the progress of the disease the circulation through
the liver is so impeded as to cause ascites, the diagnosis is much
more easy. The cases most difficult to distinguish from it are
those in which ascites is associated with great enlargement of the
spleen. It now and then happens that a man is brought into our
London hospitals with great ascites, and most of the other symp-
toms of cirrhosis. After a time the ascites diminishes, and the
spleen is found enormously enlarged. The ascites may completely
disappear, and the patient regain health enough for his former
pursuits. I have lnet with three cases of this kind, but have never
ascertained by dissection what the disease really is. The spleen is
much enlarged, which it is not in cirrhosis, and the complexion
CIRRHOSIS.
127
may not be sallow, but in other respects the characters of the two
diseases are almost identical.*
The only other diseases we are likely to confound with cirrhosis,
after the occurrence of ascites, are chronic peritonitis, and malig-
nant disease of the liver.
In chronic or adhesive peritonitis, as in cirrhosis, fluid may be
effused into the cavity of the peritoneum, the limbs may be wasted,
and the urine high-coloured and highly charged with lithates.
But in chronic peritonitis, there is not the sallow look of cir-
rhosis, and there is pain and tenderness all over the belly, with
hectic fever and sweating ; symptoms which are usually wanting
in the advanced stages of cirrhosis.
In peritonitis, the fluid poured out is seldom so abundant as in
cirrhosis. The belly may be as much distended, but this is owing
in great part to the intestines being distended by gas — which
they always are in peritonitis. The ascites, too, does not persist
as it does in cirrhosis. If the fluid be serous, it soon becomes
absorbed.
There is not the same impediment to the absorption of the
fluid in peritonitis, as in pleurisy. In empyema, when the lung
has been much compressed and is irrecoverably bound down by
false membranes, the fluid in the cavity of the pleura, even if
serous, cannot be absorbed faster than the space it occupies can
be filled up by the contraction of the side, and the encroachment of
the opposite lung ; and when these means have attained their
limit, it is physically impossible that a drop more of the fluid can
be absorbed. A collection even of serous fluid may consequently
remain in the cavity of the pleura for years.
But, in peritonitis, there is no such impediment to the absorp-
tion of the fluid. Even if the intestines be bound down by ad-
hesions, the abdominal parietes may continue to fall in until
all the fluid is absorbed. But when the fluid is absorbed, the
folds of intestine, which arc united to each other and to the parts
with which they have been brought into contact, are always dis-
tended with gas. The abdomen is large, and gives out a tym-
panitic sound on percussion.
* It may be, that in these cases the liver is diseased as well as the spleen.
The ascites may depend on obliteration of some branches of the portal vein,
and may gradually disappear, as the requisite freedom of circulation is re-
stored through other channels.
4
128
ADHESIVE INFLAMMATION OF THE LIVER.
In peritonitis, too, even when there is much fluid in the sac of
the peritoneum, the sense of fluctuation derived from percus-
sion, is usually much less distinct than in ascites from disease of
the liver. In peritonitis, contiguous loops of intestine are
glued together, and the fluid is contained in pouches, so that the
shock communicated by percussion is propagated through it less
perfectly than when it is contained in a single cavity.
We are still further guided in distinguishing the two diseases,
hy knowledge of the most common circumstances in which they
respectively occur. Cirrhosis is rarely met with in persons of
temperate habits, or under the age of thirty. Chronic peritonitis
occurs at all ages, without any marked relation to particular habits
of life, and in grown-up persons is almost always dependent on
the presence of tubercles, which are deposited in the lung, as
well as on the peritoneum. If there he no evidence of the pre-
sence of tubercles in the lung, we have strong presumption that
the fluid in the peritoneum is not the result of chronic inflamma-
tion of that membrane.*
Cancer of the liver has also, in some cases, many symptoms in
common with cirrhosis. It occurs at the same period of life; the
patient may have the same sallow look ; there may be some
degree of ascites, with loss of strength, disordered digestion, and
scanty, and high-coloured, and turbid urine.
But in cancer, the ascites seldom attains the degree it has in
cirrhosis. The fluid is seldom in sufficient quantity to render the
walls of the belly tense. In cancer, too, as the disease advances,
the liver always grows larger, and, in most cases, where the can-
cerous tumors so obstruct the circulation through the liver as to
cause ascites, the liver can he felt extending far below its natural
limits. In the advanced stages of cirrhosis, on the contrary, the
liver shrinks, and is generally smaller than in health. In
cancer, there is usually hectic fever with sweating ; in cirrhosis,
the skin is dry and rough.
We may distinguish the diseases still further hy considering
the previous habits of the patient. Cancer has no marked depen-
dence on particular modes of life, and is perhaps as common in
the higher classes as in the lower. Confirmed cirrhosis, on the
* Many of the distinguishing marks of cirrhosis here noticed, were pointed
out by M. Becquerel, in the elaborate paper in the Archives Generates, before
referred to.
CIRRHOSIS.
120
contrary, is rare in the higher classes, and is seldom met with,
except among those of the poor in our large towns, who have
suffered privations, and have been long in the habit of drinking
spirits to excess.
Cancer of the liver is, besides, generally consecutive to cancer
of some other part — and the presence or absence of this may still
further aid our judgment.
Treatment. — From what has been already said of the nature
of cirrhosis, it is quite clear, that it is only in the early stage of
the disease that we can materially benefit the patient. During
this stage, while the inflammation is active, it may perhaps
be in our power to lessen the amount of effusion, and before
the lymph effused has become organised, even to cause its removal
by absorption. But when fibrine has been thrown out in large
quantity, and when it has become organised, or is otherwise
incapable of removal, and has already by its contraction caused
much impediment to the flow of portal blood, and materially
impeded the due secretion of bile, medical treatment can be
only palliative. It is, therefore, of the utmost importance that
the disease he detected early, in order that we may be able
to obviate such grave and irremediable effects. But, as we
have seen, this is not without difficulty, as the symptoms
are then often few and very obscure, and it is only by con-
sidering the previous habits of the patient, that we see in them
the early tokens of organic disease. In the person of a spirit-
drinker, we should never neglect pain and tenderness in the
region of the liver, especially if associated with some degree of
fever.
At the commencement of the disease, the best treatment is,
cupping over the liver, with saline medicines and low diet.
While there is much tenderness, and the patient is feverish,
nothing produces so much relief as cupping. We must hear in
mind, however, that hard drinkers bear bleeding ill, and be
careful not to push this remedy too far. Delirium tremens, or
other alarming disorder, may bo the consequence of its rash and
inordinate employment. When bleeding is not considered safe,
much benefit may he derived from the application of a blister.
When the fever has abated, and the liver is still large, mercury
K
130
ADHESIVE INFLAMMATION OF THE LIVER.
and iodide of potassium are the medicines from which most benefit
may be expected. Blue pill may he given in moderate doses, so
as slightly to affect the mouth ; or iodide of potassium may be
given internally, and, at the same time, the iodine ointment be
rubbed into the side.
We should endeavour, too, to make the patient give up his
pernicious habit of drinking. We may infer from the slight
degree of fever, and the slight pain that often attend the early
stages of cirrhosis, that the lymph is thrown out, not all at once,
from a single attack of inflammation, but by little at a time, in
successive attacks, of which none is sufficiently severe to cause
serious illness. The mischief is done gradually, under the
gradual and repeated operation of the cause. By changing the
habits of the patient, future attacks may be prevented, and the
disease be stayed before it has produced fatal organic changes.
But too often our powers of persuasion will fail. The patient
will pursue his ruinous course, in spite of all our warning.
Very often, too, from the insignificant character of the early
symptoms, and from general disregard, among the labouring
classes, of ailments that do not stop them from wmrking, advice
is only sought after the occurrence of ascites.
And then, the disease has proceeded so far as to be in great
measure beyond the power of remedy. The presence of ascites
proves that there is already a mechanical obstacle to the circula-
tion through the liver ; and this obstacle we have no means of
removing.
The case is analogous to that of stricture of the intestine from
the contraction and organisation of lymph effused under the mu-
cous coat, or of disease of the valves of the heart. There is a
permanent mechanical impediment to the due performance of the
functions of the organ. The disease will, sooner or later, but
inevitably, prove fatal.
At this time, that is, after the occurrence of ascites, we can do
little good, and may do much harm, by bleeding, courses of mer-
cury, or other lowering measures. Such measures cannot remove
the impediment, and they weaken the patient, at a time when his
assimilating powers can scarcely maintain his actual condition.
The wisest plan is, to prescribe careful attention to diet, which
should be light and nourishing ; some light tonics, if the patient
CIRRHOSIS.
131
can bear them ; and avoidance of all unnecessary fatigue. An
occasional tepid, or warm bath, will soften the skin, and allay
thirst. The bowels should be kept well open — as any degree of
constipation increases the sense of distension which the patient
suffers ; but care should be taken not to bring on purging, which
would reduce the strength.
Even at this stage of the complaint, I have, I think, seen
good result from mild diuretics, with small doses of iodide of po-
tassium ; but these medicines should be left off if they irritate
the bowels and excite purging. A flow of urine, however copious,
will not remove, or even very much reduce, the ascites. Of this
I had clear proof in a patient admitted into King’s College Hos-
pital in the winter of 1840. He was a broker’s porter, had
drunk hard of spirits, and bad long suffered occasional pains in the
right hypochondrium. A month before his admission, he noticed
that his belly was much swelled, and, soon afterwards, his legs
began to swell.
At the time of his admission, he presented the symptoms of the
advanced stage of cirrhosis. The belly was enormously distended
with fluid, and large veins were seen running upwards on each
side from the flanks.
On further inquiry, we leamt that he had also the symptoms of
diabetes. He had a craving appetite, with great thirst, and passed
daily from ten to twelve pints of urine, which was of light amber
colour, transparent, and of sp. gr. 1040 — 1045. It contained
no albumen, but a large quantity of sugar. He continued in
the hospital rather more than a month, when he died of phlegmo-
nous erysipelas of the right thigh.
Notwithstanding the enormous quantity of urine passed daily,
there was not the slightest diminution of the ascites. The belly
was enormously distended to the last. After death, the liver was
found very large and hob-nailed, and united to the diaphragm
and abdominal parietes, by bands of adhesion of long standing.
The gall bladder was filled with bile, of a pale orange colour.
All the capillary vessels, in the posterior part of the peritoneum,
to which the blood had gravitated, were beautifully injected and
varicose. The heart was small, and had no other mark of disease
than a white spot on its outer surface. The kidneys wero healthy.
Hydragogue purgatives have as little power to reduce the
K 2
132
OTHER KINDS OF INFLAMMATION
ascites, and may do much .harm by weakening the patient.
When the patient is much reduced in flesh and strength, they
cause great prostration, render the tongue dry and brown, and, by
lowering the force of the circulation, tend to increase the ascites
rather than diminish it.
It sometimes happens that the ascites, by impeding the descent
of the diaphragm, causes great distress of breathing, especially
in asthmatic persons, or when the breath is shortened by catarrh.
This distress may he relieved for a time, by letting out the fluid
by tapping. After the operation, the patient draws his breath
more freely, and feels as if a weight were taken off his chest.
Sometimes, owing perhaps to pressure being removed from the
kidney, he makes more water after the operation, than he
had been making before. But this relief is only temporary.
The fluid accumulates again in the belly, and, after a time, vary-
ing, according to the degree of obstruction, from a few days to
three or four weeks, reaches its former amount.
The operation should never be had recourse to, unless the
difficulty of breathing, or the other evils that result from disten-
sion of the belly, are very distressing. For the ascites speedily
returns, and the operation has consequently the effect of with-
drawing a large quantity of serum from the vessels. By repeat-
ing the operation frequently, the system may in this way be com-
pletely drained of the serous part of the blood. The patient will
fall into a state of great prostration, with complete loss of appe-
tite, a dry and brown tongue, and will die much sooner than if
nothing had been done.
Suppurative inflammation of the liver and adhesive inflamma-
tion, the forms of inflammation hitherto considered, leave per-
manent traces — collections of pus and contracted fibrine — that
may be readily discovered after the death' of the patient. But
there are probably various morbid states of the secreting sub-
stance of the liver, which, in the latitude usually given to the
term, inflammation, should be comprehended under this title, in
which, as in erysipelas of the face, and in the affection of the
OF THE SUBSTANCE OF THE LIVER.
133
joints in rheumatic fever, the fluids poured out during the inflam-
matory process, become again absorbed, leaving no permanent
traces, or only such traces as caunot well be distinguished. In
such cases, the nature of the morbid process can be judged of by
the symptoms only, unless the patient happen to die during the
acute stage of the malady, and while its effects are still present.
Such a morbid process in the liver often occurs in pneumonia
of the right lung, perhaps from the heat developed in the seat of
the neighbouring inflammation. The patient is sometimes jaun-
diced, and if the disease prove speedily fatal, the upper part of
the right lobe of the liver is found softened and much altered in
texture. This change in the condition of the liver was noticed
by Abercrombie, who has described it under the term — simple
“ ramollissement” of the liver. He says : — “This consists of a
broken down, friable, and softened state of a part of the substance
of the liver, without any change of colour. It is, in general, most
remarkable on the convex surface, extending to a greater or less
depth ; it is accompanied by a separation of the peritoneal coat
at the part, and sometimes there appears to be a loss of sub-
stance, as if a portion had been torn out, leaving a ragged ir-
regular surface below. The softened portion has commonly so
far lost its consistence, that the finger can be pushed through it
with very little resistance ; and in some cases the affected part is
infiltrated with sanious or puriform fluid, not collected into
abscesses, but mixed irregularly through the substance of the
softened part This appearance we have every reason to consider
as the result of inflammation. It is found in combination with
abscess or other marks of inflammation, and I have very often
observed it on the upper surface of the liver, in connexion with
extensive inflammation of the right lung. In these cases there
was not, in general, any symptom indicating that the liver was
affected. Mr. Annesley states that this appearance is frequently
met with in India, in persons who have died rapidly from cholera
or dysentery.”
I have often met with this softening of the part of the liver
next the diaphragm, in cases of extensive inflammation of the
right lung, but have never found pus in the softened portion. I
imagine that suppuration takes place seldom, and that in almost
all these cases in which the patient recovers from the pneumonia,
the liver regains its natural texture.
134
OTHER KINDS OF INFLAMMATION
It is probable that inflammatory disease of other adjacent
organs, and especially of the right kidney, sometimes causes a
similar change in the texture of the liver, now and then termi-
nating in the formation of pus. Among the cases of abscess
of the liver published by Andral, there is one (Clin. Med. iv. obs.
29) in which it is, I think, probable, that the inflammation origi-
nated in this way.
It certainly, however, very rarely happens that inflammation of
the right lung or kidney, causes abscess of the liver, hy the heat
developed during the process of inflammation. If this excite any
morbid process that can be comprehended under the term, inflam-
mation, it is such as to leave, in general, no permanent traces.
Dr. Graves has remarked, (Clinical Medicine, p. 564,) that
jaundice, and other symptoms indicative of inflammatory action
in the liver, sometimes come on during rheumatic fever ; but he
does not seem to have met with an instance in which it proved
fatal. It is at present impossible to decide whether the inflam-
mation, in such cases, involve the secreting substance of the
liver, or tbe gall-ducts. It seems to admit of perfect recovery.
Dr. Graves has also observed enlargement of the liver, with
pain, or tenderness, and jaundice, to come on during the course
of scarlatina. He regards the affection as inflammatory, and re-
commends antiphlogistic measures for it.
In one of his clinical lectures, (Clinical Medicine, p. 569,) he
refers to two cases of this kind, that happened in the same week
in the Meath Hospital. One of these patients, a little boy, was
seized with scarlatina in a very severe form, with high fever, and
a brilliant eruption all over the body. After two days, he had
evident symptoms of disease and enlargement of the liver. The
other patient was a young man, who had scarlet fever of a milder
form. “ On the third day, he likewise got inflammation of the
liver, but was cured by general and local antiphlogistic treat-
ment."
Dr. Graves states that, in persons whom an attack of scarlatina
has left in a feverish condition, he has often found the liver in a
state of inflammation — as proved by the benefit derived from local
antiphlogistic means ; but inflammation “ of rather a chronic
character, without any of that remarkable pain and tenderness
OF THE SUBSTANCE OF THE LIVER.
135
which characterises acute hepatitis.” He considers that this con-
dition of the liver retards and prevents convalescence.
No cases of this kind have been accurately recorded, and we
cannot yet decide, if the disease be inflammatory, what elements
of the liver are involved.
136
SUPPURATIVE INFLAMMATION
Sect. IY. — Inflammation of the veins of the liver — Suppurative
inflammation of the portal vein — Adhesive inflammation of
branches of the portal vein — Inflammation of branches of the
hepatic vein.
Inflammation of the veins of the liver. — Inflammation, in veins,
as in other textures, may he suppurative, that is, it may lead to
the formation of pus ; or it may be adhesive, and lead only to the
effusion of coagulable lymph, which blocks up and obliterates the
vein. But in the inflammation of veins that leads to the forma-
tion of pus, coagulable lymph is usually poured out as well as
pus ; and the pus does not fill all the inflamed portion of the vein,
hut is interrupted here and there by plugs of fibrine, so as to form
a string of abscesses along the vein.
Inflammation of the trunk of the vena port® is of very rare
occurrence. From being so deep seated, this vein is not liable
to wounds or other injuries — the most common causes of in-
flammation of other large veins.
The following case, published by M. Lambron, in the “ Ar-
chives Generales de Medicine,” for June, 1842, is the most com-
plete case of the kind I have met with. Here, inflammation of
the trunk of the vena port® was caused by a fish-bone, which
passed through the pyloric extremity of the stomach and the head
of the pancreas, and stuck in the superior mesenteric vein.
The patient, a man 69 years of age, was admitted into “ la Pitie, ” on the
4th of June, 1841. For some weeks, he had been suffering at the stomach,
with occasional nausea, and his bowels had been much confined. On
account of these ailments, a week before his admission, he took a grain of
tartar emetic, which produced no amendment.
The day he entered the hospital, he was seized with shivering and nausea,
and the following night he slept ill.
On the morning of the 5th, he was carefully examined. His pulse was
nearly natural, and his breathing quite tranquil. His tongue was white, he
had some degree of nausea, and his bowels were confined. He complained
of constant uneasiness, with paroxysms of pain, which he compared to very
OF THE PORTAL VEIN.
137
severe cramp, in the right hypochondrium, but pressure on that part
gave hardly any pain. The liver and the spleen were of natural size. The
other functions seemed duly performed. (Wine-lemonade ; low diet.)
The 6th and 7th of June, he had no rigors; the pain in the right hypo-
chondrium was very severe, but there was no tenderness. The tongue
was covered with a whitish coat, there was some nausea, and the bowels
were still costive. (A grain of tartar-emetic ; veal broth ; julep.)
On the 8th, he suffered still more, and the skin and conjunctive had be-
come slightly yellow.
On the 11th, the jaundice was more marked, and the urine, as tested by
nitric acid, contained bile. The pain in the right hypochondrium persisted,
with exacerbation from time to time. About f.gvj. of blood were taken
from the side, by cupping.
On the 12th, the pain was less, but he had nausea, and in the evening,
a shiver followed by heat and sweating. His tongue was dry, and covered
with a blackish coat. Hiccough, and some greenish liquid evacuations.
Pulse 96. The spleen was not perceptibly enlarged. ( Quiniee snip hat..,
grs. iij.)
On the 13th, he was nearly in the same state. Some rigors occurred during
the night, but they were not succeeded by a hot stage, and the sweating was
less profuse than before. Occasional hiccough. Pulse 80. (A blister was
applied to the stomach ; the quinine was continued.)
The rigors and the hiccough continued to recur.
On the 15th, the fits, like those of ague, recurring more or less regularly,
and not yielding to sulphate of quinine; the hiccough, the jaundice, the pain
in the right hypochondrium, the absence of disease in other parts of the body,
and the nearly natural size of the spleen, led to the inference that the af-
fection was hepatic phlebitis.
The 17th, the patient was in a typhoid state. The 18th, he was a little
better, and the jaundice less marked.
The 24th, he felt better, and asked for something to eat. In the evening,
he was seized with violent shivering with fever, but now the different stages
were confounded, and he shivered while his body was covered with sweat.
The urine contained much less bile.
The 25th, the fever had not ceased, and seemed likely to become continued.
The skin was covered with sweat. The tongue, which had been moist for
some days before, had become again dry ; and the pains, which had ceased
for five or six days, came on again.
The 26th and 27th, the shivers recurred, with occasional hiccough, the
fever became remittent, the pulse was firm and tolerably full, but the patient
was much depressed.
The 28th and 29th, he sank lower and lower, and became slightly delirious.
Pulse 104, small, and compressible. He died in the night of the 29th.
The body was examined thirty hours after death. All the tissues were
slightly jaundiced. There was no serous fluid in the abdomen. The liver
was of natural size, and of a dark-greenish yellow, or bronze colour. It ad-
138
SUPPURATIVE INFLAMMATION
hered at some points to the diaphragm, hut its investing membranes were
otherwise healthy. The gall-bladder was of natural size, and had also formed
some adhesions to contiguous parts. It was filled with bile, which had all
the characters of ordinary bile. The gall-ducts were healthy.
The trunk of the vena portae contained a sanious fluid, with some flakes of
pus.
On tracing the mesenteric roots of the vein, a fish-bone, the size of a large
pin, was found stuck into the trunk of the superior mesenteric vein. The
hone, implanted in the head of the pancreas, transfixed the vein from above
downwards, and from before backwards. At the point where it was pierced
by the hone, the mesenteric vein was blocked up by false membranes, which
adhered firmly to its inner coat. The false membranes extended from the
mouths of the small veins which come directly from the upper part of the
duodenum to the orifice of the splenic vein, becoming less and less firmly
adherent. Below this obstruction the roots of the mesenteric vein contained
some fibrinous coagula for an extent of some inches, but were otherwise
healthy.
The splenic vein was healthy, but contained some reddish fluid like that
in the portal vein, from which it had probably flowed into the splenic vein
after death.
The trunk of the portal vein was not closed, but was narrowed by false
membranes adhering slightly to its coats, which were only a little thickened.
It contained pus mixed with blood, and at some points, pus like that of an
abscess. The hepatic divisions of the vein were some of them filled with the
same reddish liquid, with their coats in some parts healthy, in other parts
inflamed, thickened, and coated by false membranes. Others contained
only clots of blood, which extended to very small ramifications of the vein.
Other branches again were perfectly healthy.
The fiver contained no abscesses, but its tissue about the transverse fissure
was very soft. In parts of the fiver supplied by those branches of the portal
vein that remained healthy, there was no change of texture. The lobules, of
a greenish-yellow colour, were distinct, and the interlobular spaces, as well
as the intra-lobular vein, were red from the blood they contained.
In the parts supplied by those branches that were filled with coagula, the
lobules were likewise distinct, but were less red at their margins and centres.
Lastly, in the parts supplied by the branches of the vein that contained pus
and were inflamed, the form of the lobules was still preserved, but the inter-
lobular tissue was very soft, and the divided intra-lobular veins seemed empty
of blood and gaping.
The hepatic veins were quite healthy, and contained very little blood.
On the posterior wall of the stomach, near the pylorus, was a brownish
spot, corresponding to one end of the fish-bone, and on the inside, at the
same spot, there was a slight depression capable of lodging the head of a
pin. It was clear that the bone had passed through the stomach at this spot,
pierced the head of the pancreas, and, going still onwards, had stuck into the
mesenteric vein, and caused all the subsequent disorder.
The kidneys, the spleen, and the intestines were healthy. In the right lung,
OF THE PORTAL VEIN.
139
there was some degree of hypostatic pneumonia, but neither lung contained
anything like an abscess.
The heart was large, and contained some clots. The right ventricle con-
tained a fibrinous clot, which extended into the pulmonary artery.
This case is very simple. The inflammation of the vein was
caused by a mechanical injury, and there was no other disease to
interfere with or to mask its effects. The vein most probably be-
came inflamed on the 4th of June, when the patient was first
shivered. The pain at the stomach and the occasional nausea he
had some weeks previous, were most likely caused by the fish-hone
then passing through the stomach and pancreas. After the 4th of
June, the symptoms were just those we might have expected.
There were frequently recurring rigors, followed by heat and
sweating, and after a short time, typhoid symptoms — as in suppu-
rative inflammation of other large veins — while the pain in the
region of the liver, the nausea, the hiccough, the jaundice, and the
absence of marked disorder of other organs, showed that the liver
was the chief seat of the local disease. The deep situation of the
vein explains the absence of tenderness.
In the following case, for notes of which, as well as an oppor-
tunity of examining the parts after death, I am indebted to
Mr. Busk, the inflammation of the portal vein had a different
origin, and led to somewhat different results, hut was marked
by nearly the same train of symptoms. I cannot describe the
case better than in Mr. Busk's own words :
“ May, 1844.
“ My dear Budd — I have sent you what I think you will consider a very
interesting specimen. It was procured from a man who died last Sunday,
after an illness of seven weeks. He was a patient of Mr. Sherwin’s, and I
have seen him frequently for the last six weeks. His case was extremely
obscure, hut I surmised from the first, that we should find suppuration in
the liver.
“ He was a very strong robust man, an engineer in the dockyard at Wool-
wich, and had never been out of England, and was of very sober, temperate
habits, married, with one child. Had always enjoyed good health, with the
exception of occasional pain in the abdomen, which was not considered of
any importance till his last attack. He never had ague.
“ Seven weeks ago, he was seized rather suddenly with severe pain in the
abdomen, which obliged him to keep his body bent forward, and he had a
severe rigor. I saw him about a week afterwards, and he had then the ap-
pearance of great depression. He complained of severe, but only occasional.
UO
SUPPURATIVE INFLAMMATION
pain in the epigastric region, predominating on the right side. The pain
was not increased by pressure. It did not appear to be of a piercing
character, hut was attended with a feeling of extreme sinking and distress,
and was relieved by morphia. It recurred several times a-day at irregular
intervals, and about twice in twenty-four hours he had a severe rigor, fol-
lowed by most profuse sweating. There was no distension of the belly,
and no enlargement of the liver could be detected on the most careful exami-
nation, nor was there any tenderness in the hepatic region.
“ When I first saw him, the evacuations from the bowels were light coloured
and very fetid, but he was not jaundiced. Soon afterwards, however, he be-
came jaundiced, and the urine contained bile. The jaundice went off in a
few days, and the evacuations became of natural colour and consistence. At
the same time, the urine lost the bile, and threw down a very copious lateri-
tious sediment, which continued to the last. The jaundice passed off sud-
denly, and the change in the character of the evacuations was preceded by a
copious discharge of nearly pure bile.
“The symptoms continued with little change to his death. Pie gradually
sank, becoming much emaciated. He never vomited, and had a great desire
for oysters, which were almost his whole support.
“ On examination of the body, the lungs were found perfectly sound.
“ The peritoneum contained several pints of straw-coloured serous fluid,
mixed with flakes of coagulable lymph ; and the stomach, transverse colon,
and great omentum, were all glued together by soft lymph.
“ The liver was large, and extended to the left side. Its convex surface had
a coating ofpuriform matter, and was of a dark colour. On raising the an-
terior margin, it was found that the concave surface, including the portal
fissure and behind it, was adherent to the stomach and surrounding parts :
and on separating the adhesions, the substance of the left lobe was found to
be occupied by numerous abscesses, which were bounded externally by the
adhesions and by the wall of the stomach. The upper surface of the left
lobe was closely adherent to the diaphragm, and in the middle of this portion
of the diaphragm there was a circular space, about the size of a shilling,
having a semi-gangrenous appearance, opposite to which on the upper surface
of the muscle the base of the lung was firmly adherent, and pus was deposited
in its substance. On detaching the liver from the other parts, a very large
collection of thick pus was found in the portal fissure. Pus could be pressed
out in great quantity from the dilated portal vein, and was also deposited in
the areolar tissue surrounding it. The whole of the left lobe was occupied
by innumerable abscesses of all sizes, so as to resemble a coarse sponge
filled with pus. In most of these abscesses, the pus was thick and white,
but in a few it was of a bright yellow. There were also numerous abscesses,
some of them of considerable size, in the right lobe.
“ The portal canals, in the left lobe especially, were thickened, white and
firm ; and, as far as I could ascertain, the gall-ducts were healthy. I have
no doubt tbe abscesses were connected with branches of the portal vein.
In a portion of the surface of the liver, which I have sent you, near the
OF THE PORTAL VEIN.
141
fissure in the anterior margin, you will observe a chain of small abscesses,
apparently following the course of a vessel, and showing in a very striking
manner the real nature of the disease.
“ The gall-bladder was distended by a very pale mucous fluid, and, like the
ducts, was perfectly healthy.
“ The spleen was of natural size, and except two small superficial abscesses
on that part of the surface which hounded an abscess beneath the liver, was
quite healthy.
“ The pancreas was healthy.
“ The splenic and superior mesenteric veins were healthy, but immediately
after their junction the vena portse was extensively ulcerated, and what re-
mained of its inner surface was covered by a buff-coloured false membrane.
The tissue in which this part of the vein was lodged, was indurated and
black ; and immediately in contact with the vein were large and suppurated
mesenteric glands. The whole mesentery was much thickened, and the
glands much enlarged, and in a state of suppuration.
“ I have sent you the mesentery with the pancreas and duodenum, and as
much as I could get of the vena portae, and of the splenic and superior me-
senteric veins. You will see the commencement of the diseased part of the
vena portae, and its apparent connexion with the suppurated glands, which
I am inclined to believe were the origin of the inflammation of the vein.
“ The stomach and intestines were carefully examined throughout, and no
morbid appearances were found in them.
“ The kidneys were pale and quite healthy.”
The origin of the disease in this case is very obscure. The
most probable supposition is, that the man had long had disease
of the mesenteric glands (perhaps the result of fever), which
caused only the occasional pain in the belly to which he had
been subject, till an abscess in one of these glands burst into the
trunk of the portal vein, and occasioned the inflammation of the
vein and the consequent disease of the liver, of which the man
died. The inflammation of the vein occurred, no doubt, seven
weeks before death, when he was seized suddenly with such severe
pain in the belly, and had, for the first time, a severe rigor.
After this, the symptoms were very like those in the case before
related ; and the frequent recurrence of rigors followed by profuse
sweating, together with the sense of sinking and general distress,
the pain in the right epigastric region, and the jaundice, were
enough to justify the opinion Mr. Busk at once formed, that the
liver was the seat of suppuration. The formation of pus in the
areolar tissue about the portal vein, was perhaps consequent on
ulceration of the vein. From there having been no vomiting, and
no tenderness of the belly, at least at first, it would appear that
142
SUPPURATIVE INFLAMMATION
the general inflammation of the peritoneum was likewise conse-
cutive to inflammation of the vein, and that it occurred hut a short
time before death.
This case affords strong confirmation of the opinion I have
already expressed, that pus-globules brought to the liver by the
portal vein, usually become all arrested there, and do not pass
through, as they often do through the lungs, to cause scattered
abscesses in other organs. It is for this reason that suppurative
inflammation of a vein that feeds the vena portae, kills less quickly
than suppurative inflammation of a vein that returns its blood
immediately to the lungs. The blood is filtered, as it were, of pus,
in passing through the liver, and the local disease is confined to
that one organ.
If, instead of involving the trunk of the portal vein, the in-
flammation involve only some of its hepatic branches, the patient
may recover, and may enjoy tolerable health for years after. This,
happened, I think, in the person of my late colleague, Mr. Lawson,
consulting surgeon of the Dreadnought, who died of dropsy from
granular kidney, in the spring of 1840.
Mr. Lawson had in early life been much in India, but returned
to England ten years before his death, and was soon after appointed
resident surgeon to the Dreadnought. He continued in this office
several years, and then settled in the city. He occasionally vomited,
especially after having eaten or drunk more than usual, and had
an occasional fit of gout, but otherwise Ills health was pretty good,
till some months before his death. Lie had a strong impression
that he had some disease of the liver, the result of an acute
attack he had in India, but few of his medical friends thought so.
He was stout and cheerful, had no pain in the side, and his com-
plexion was remarkably clear.
The examination of the body was made by Mr. Busk, in pre-
sence of Dr. Bright and myself. The liver had no unnatural ad-
hesions, and there were no marks of inflammation of the capsule,
but its surface was deformed by deep linear fissures. On cutting
across these fissures, there was found at some points a small stellar
cicatrice, of white cartilaginous substance ; at other points,
a small abscess, containing white pus. There were a great num-
ber of these abscesses, but all were in the lilies of the fissures, and
all were small ; not one was larger than a filbert.
The capsule and the peritoneum covering the liver had under-
OF THE PORTAL VEIN.
143
gone no change of structure, even at the fissures. They were
merely drawn in from atrophy of the hepatic substance beneath.
The lungs were not adherent to the pleura costalis, and pre-
sented no marks of former inflammation.
The stomach was large, and the pylorus was somewhat con-
tracted by a cartilage-like tissue under the mucous coat — changes,
which accounted for the vomiting to which Mr. Lawson had been
subject.
The vessels of the fiver -were not traced, and at the time the
examination was made, the precise seat of the abscesses was not
ascertained. The linear fissures on the surface of the liver
scarcely, however, leave a doubt that the abscesses were in
branches of the portal vein. There had been inflammation of
some branches of the vein, a string of small abscesses had formed
along them, separated here and there by a plug of lymph, the
parts of the liver which those branches supplied became atrophied,
and, in consequence, the capsule was drawn in, and the surface
marked by fissures corresponding to the obliterated branches of the
veiu. Enough of the liver was left for the purpose of secretion,
and the portal blood passed freely through it, so that no serious
disorder of health resulted.
Inflammation of a branch of the portal vein, may he caused
by an abscess of the liver, consequent on phlebitis of some dis-
tant part. This happens, however, very rarely ; probably on
account of the coats of the vein being thick and surrounded by
areolar tissue. The only instance of the kind I have met with,
is in a case sent me by my friend, Dr. James Russel, of Birming-
ham. The patient, a man of middle age, had his leg amputated
on the 18th of March, on account of gangrene coming on after a
compound fracture. Three days after the operation, he had a
rigor, followed by sweating. The rigors recurred, other constitu-
tional symptoms of purulent phlebitis came on, he got gradually
lower, and died on the 20th of April. Occasional pain at the
epigastrium, was the only sign that the liver was diseased. An
abscess was found in the apex of each lung, and three or four
abscesses in the liver. A large branch of the portal vein, in con-
tact with one of the abscesses, contained a hollow cylinder of
lymph, about two inches in length, filled with pus. The abscess,
reaching the coats of the vein, had probably excited inflammation
144
ADHESIVE INFLAMMATION OF BRANCHES
of its lining membrane, just as an abscess, reaching the surface
of the liver, excites inflammation of the peritoneum above it.
Mere adhesive inflammation of branches of the portal vein,
does not prove fatal, like suppurative inflammation ; and on this
account, and from the difficulty of distinguishing the different
inflammatory diseases of the liver during life, we cannot yet give
its clinical history. The patient recovers, and when he dies,
perhaps some years after, of another disease, we see merely the
ultimate changes to which obliteration of branches of the portal
vein leads. These changes are very strildng and characteristic.
The surface of the liver is marked by deep linear fissures, corre-
sponding to the obliterated branches of the vein, and caused by
atrophy of those portions of the liver which the obliterated
branches supplied. Rokitansky, who has well described these
appearances, states that they are very common in persons who die
in the hospitals in Vienna. They are by no means uncommon in
this country. During the past year, I have had an opportunity
of examining three good specimens of this disease. The first
was in a liver, which was sent me last November, by my brother.
Dr. William Budd, of Bristol. The person from whom it was
obtained was a sailor, who died in St. Peter’s Hospital, Bristol,
of dropsy from granular kidney.
He had been a hard drinker, had been in hot climates, and had had re-
mittents, one attack, not many months before his death. There was con-
siderable nausea, but no ascites. There had been deep jaundice about a week
before death. This had lessened a good deal, but there was still a light
yellow stain of the skin.
He died of cerebral disorder— apparently the result of poisoning of the
blood by urine and bile.
The liver was much deformed by deep linear fissures across its upper and
its under surface.
On the upper surface of the right lobe were two spots, nearly the size of
half-a-crown, covered by a false membrane, a line in thickness, having the
toughness and the look of cartilage. From these spots the false membranes
shaded away to a thin film, but this did not cover the whole of the convex
surface of the right lobe ; and on the convex surface of the left lobe, and on
the under surface of the liver, there was no false membrane, although the
surface was much fissured.
On separating the fissures, and tearing and scraping away the hepatic
substance by the handle of the scalpel, solid fibrous twigs were left, which
were found to be continuous with branches of the portal vein. The trunk of
10
OF THE PORTAL VEIN.
145
the portal vein and its first divisions appeared healthy. About the small
divisions still pervious, the areolar tissue seemed thickened, and the artery and
duct were more adherent to the vein than natural. The impervious twigs of
the vein, in a section of the liver made across them, looked like small stellar
cicatrices, and in many of them could be seen a yellow point, the orifice of a
divided gall-duct.
The lobular substance of the liver was of a uniform deep chocolate colour,
and rather soft, so that it was readily scraped away from the fibrous twigs.
The disease was not confined to one part of the liver. One surface was just
as much fissured as the other.
The hepatic artery and the hepatic veins appeared healthy.
The gall-bladder and the large ducts were stained with bile, but healthy.
The liver was adherent to the diaphragm and abdominal walls, by bands of
old tissue, at the spots covered by thick false membrane.
The spleen was large and indurated. There were no adhesions, or other
traces of peritonitis, anywhere in the abdominal cavity, except on the surface
of the liver.
The duodenum was much stained by deep olive bile, and from the opening
of the common duct to six or eight inches down, there was deep crimson in-
jection of the mucous coat.
The right lung was universally adherent to the costal pleura ; the left lung
was quite free.
The heart was immensely hypertrophied. There was no important dis-
ease of its valves, but much ‘ atheromatous ’ deposit in the aorta.
Both kidneys were in a very advanced stage of granular disease.
Another instance of the same disease, that has recently fallen
under my notice, was in a man who died in King’s College Hos-
pital, of cancer of the penis. This man, who was a soldier, and
had served in the Peninsula, had been at one time a hard drinker.
He had neither ascites, jaundice, or other symptom of diseased
liver. The liver, as in the instance just related, was crossed by
deep fissures, but there were fewer of them, and there were no
marks of inflammation on its capsule. The tissue of the liver
seemed healthy, and could be readily scraped away from the ob-
literated twigs of the portal vein. The spleen was large and firm,
and its capsule was much thickened, and presented some cartila-
ginous-looking plates.
Another specimen, precisely similar, was sent me by Mr. Busk.
It was taken from a sailor, who died of phthisis, much emaciated.
There was no mention of hepatic disease in the notes taken of his
case. The liver weighed only two pounds one ounce and a half,
and, as well as the spleen, adhered to all the surrounding parts
L
146
INFLAMMATION OF BRANCHES
by means of old tissue. There were no traces of former peri-
tonitis, elsewhere.
It appears, then, that obliteration of branches of the portal
vein causes atrophy of those parts of the liver which the ob-
structed branches supplied, and consequent diminution of the size
of the organ. When an obliterated branch is near the surface,
the capsule gets drawn in by the atrophy of the intervening
lobular substance, and the surface is marked by a linear fissure.
The lobular substance, supplied by other branches of the vein,
may remain uninjured. A portion of the liver is lost, propor-
tionate in amount to the number and size of the obliterated
branches of the vein — and the person must suffer all the evils
which such a loss entails. The disease, in its effects, is like that
form of adhesive inflammation of the substance of the liver,
which leads to new fibrous tissue in the portal canals of consi-
derable size ; and in two of the three instances I have mentioned,
was attended by marks of disease in the capsule of the liver, and
in the spleen, such as are usually found in that affection. In
these instances, it was probably brought on by spirit- drinking.
Bokitansky is of opinion that this disease of the liver is in many
cases the result of direct communication between the venous sys-
tem of the liver and that of the body, in consequence of the um-
bilical vein remaining pervious. He says that in extreme cases,
it may become the cause of ascites.*
Suppurative inflammation of a branch of the hepatic vein is, as
already remarked, occasionally produced by a small abscess iu
the liver, consequent on phlebitis of some distant part. The
abscess, touching the thin coat of the hepatic vein, sets up in-
flammation on its inner surface, just as it sets up inflammation
of the peritoneum above it when it reaches the surface of the
liver. Lymph is effused within the vein, at the point where it is
touched by the abscess, the canal of the vein becomes closed at
* In the preceding chapter, (p. 127,) allusion has been made to cases in
which ascites was associated with great enlargement of the spleen. These
were most probably instances of the disease under consideration. The ascites
gradually, though slowly, diminished, and the patients were again able to
follow their former callings ; but the spleen remained large.
OF THE HEPATIC VEIN.
147
that point, and all the branches that feed it, even back to their
capillary divisions, become subsequently, and in consequence,
choked with fibrine and coagulated blood, with, here and there,
a little purulent matter. I have observed these marks of in-
flammation in a branch of the hepatic vein, in two instances
in which small abscesses had formed in the liver after amputa-
tion. In a portion of liver sent me by Mr. Busk in Novem-
ber, 1843, which was taken from a man who died of phlebitis
after amputation of the thigh, several branches of the hepatic
vein were inflamed in this way, and obviously from this cause.
The liver contained many abscesses, of the size of peas, and lined
by a distinct, but very thin membrane.
Dr. James Russel, of Birmingham, has sent me notes of a
case, in which the same changes were observed. The patient died
in the Birmingham Hospital, in 1836, eighteen days after ampu-
tation of the leg.
A somewhat similar case has been published by M. Lambron,
in the Archives Generates for June, 1842 ; but, here, the ab-
scesses in the liver were most probably caused by a cancerous
ulcer of the stomach.
From these instances, it is probable, that inflammation of one
or more branches of the hepatic vein is not uncommon in cases
where abscesses form in the liver after injuries of the head or
limbs. From want of careful dissection, this disease of the vein
must be often overlooked.
Inflammation of the hepatic vein from other causes, is, I believe,
extremely rare. The only instance in which I have seen evidence
of it, was in a man, who died in King’s College Hospital in
February, 1844. All the hepatic veins seemed thicker and more
opaque than natural, and, on examining them closely, I found
a thin false membrane on their inner surface, which in the
large veins could be readily stripped off. There was a great deal
of new fibrous tissue in all the portal canals of considerable size,
and some in the small ones, also, — enough on the whole to
render the liver tough, but not distinctly hob-nailed or granu-
lar. The liver and the spleen were united to all the adjacent
parts by means of old tissue — and there were some adhesions,
apparently of the same date, between adjacent coils of intestine.
The pericardium adhered to the heart by means of a thick layer
I. 2
14S
INFLAMMATION OF THE HEPATIC VEIN.
of tougli fibrous tissue ; and both lungs were everywhere adhe-
rent to the pleura costalis. The patient was a tailor, 52 years
of age, and for many years had been in the habit of drinking
enormous quantities of gin. It was this probably that caused the
adhesive inflammation of which so many traces were found.*
* There can be little doubt that the adhesive inflammations, of which so
many traces are found in bodies examined in our hospitals : — cirrhosis, ob-
literated portal veins, thickened capsule of the spleen, puckering of the sur-
face of the kidney from obliterated vessels, stricture of the pylorus from con-
tracted lymph in the submucous areolar tissue, and, in many cases, adhesions
of the pericardium and pleura — are mainly attributable to spirit-drinking.
The inflammation which this causes, is always adhesive.
149
Sect. V. — Inflammation of the gall-bladder and ducts — Catar-
rhal and suppurative inflammation — Croupal, or plastic, in-
flammation— Ulcerative inflammation — Effects of ulceration
of the gall-bladder and ducts — Effects of permanent closure
of the cystic and common ducts — Fatty degeneration of the
coats of the gall bladder.
The inflammatory diseases of the gall-bladder and ducts, al-
though undoubtedly of frequent occurrence, have been hut little
studied, and at present we have not materials for anything like a
complete history of them. This is to he ascribed, in part, to the
ambiguous character of the symptoms of all diseases of the liver ;
in part, to the small size of the gall- ducts, which causes them to he
often overlooked in our dissections. It should ever he borne in mind,
that the ducts, though small, are very important, from being the
only outlets for the bile secreted in those portions of the liver to
which they lead. Permanent closure of the cystic duct entirely
destroys the office of the gall-bladder ; — of the common duct, the
office of the liver itself.
Inflammation of the gall-bladder and ducts probably arises
from various causes, each of which determines in great measure
the character and the course of the inflammation, and its mode of
termination — so that we cannot expect a satisfactory account of
the different kinds of inflammation until we can arrange them
according to the causes by which they are respectively produced.
To attempt such an arrangement at present, would be premature.
We must he satisfied with what seems the nearest approach to
it ; viz. an arrangement based on the appearances found after
death.
The different forms of inflammation of a mucous membrane,
considered with reference to their effects, are,
1st, What may he called catarrhal inflammation, which merely
increases the quantity and changes the quality of the natural
mucus, often rendering it viscid, whitish, and opaque. This form
of inflammation seems to correspond in degree with the adhesive
150
INFLAMMATION OF THE
inflammation of other textures, but it is not adhesive, in the sense
before given to that word, because, by a wise provision, the matter
poured out on the free surface of a mucous membrane very rarely
becomes organised, and permanently adherent to the membrane.
2nd. Suppurative inflammation, where the matter secreted is
purulent.
3rd. Croupal, or plastic, inflammation, where the matter effused
forms a solid, albuminous layer on the diseased surface, of which,
when this is a tube, it becomes a perfect cast.
4th. Ulcerative inflammation — if, indeed, the process which
leads to ulceration can with propriety be classed with those leading
to the results before-mentioned, and he comprehended with them
under the generic term, inflammation.
All these different forms of inflammation have been observed in
the mucous membrane lining the gall-bladder and ducts, hut not
with equal frequency in its different parts. Inflammation seldom
produces changes sufficient to attract notice in the hepatic duct, or
the branches that go to form it. The coats of the gall-bladder,
and of the cystic and common ducts, are not unfrequently found
ulcerated, or much thickened and otherwise changed in texture ;
but such changes are hardly ever met with, in man, in branches of
the hepatic duct. It might have been anticipated that the gall-
bladder, and the cystic and common ducts, would be more liable
to inflammation than the branches of the hepatic duct. They are
much more liable to be inflamed by the passage of unhealthy bile,
which becomes more concentrated, and therefore more irritating,
in the gall-bladder ; they are also much more liable to disease
from the irritation of gall-stones, which are usually formed in the
gall-bladder ; and they are, besides, from their situation, liable to be
involved in diseases of adjacent organs. For these reasons, it is, per-
haps, best to consider the diseases of the gall-bladder, and of the
different portions of the ducts, separately, as far as this can be done.
Catarrhal inflammation of the ducts is, probably, not un-
common. It is not a fatal disease, and, like catarrhal inflamma-
tion of other mucous membranes, may cause no permanent
changes; so that it may often have occurred, where no traces of it
are found. It happens, however, not very unfrequently, that on
squeezing the hepatic ducts, a viscid whitish fluid oozes out, which,
HEPATIC DUCTS.
151
on examination through the microscope, is seen to be chiefly made
up of the prismatic epithethial cells of the gall-ducts. The symp-
toms we should expect in catarrhal inflammation of the hepatic
ducts, are some degree of feverishness, with slight pain in the
region of the liver, and if many of the ducts become closed by
thickening of their coats, or be choked by the viscid secretion,
slight enlargement of the liver, and jaundice.
Many of the cases of simple jaundice coming on in healthy
persons, and attended with very little pain and fever, are probably
cases of this kind.
In a severer form of inflammation, the matter secreted is
purulent, but it has seldom the visible characters of pure pus.
The pus is mixed with opaque mucus secreted at the same time,
and, it may be, with bile also. If the bile be in considerable
quantity, and ammoniacal, its alkali renders the pus glairy, and
the result is a viscid, greenish, or yellowish, fluid, very different in
appearance from pure pus.
The most striking instance of suppurative inflammation of the
hepatic gall-ducts I have found recorded, was related by Dr.
Olliffe (of Paris), at the meeting of the British Association, in
1843. It occurred in the person of an officer, who had resided
many years in India, and during that time had suffered from
“ jungle fever,” or a peculiar intermittent of tertian type, which
afterwards recurred in a slight form when he was in Italy. Many
years afterwards, other symptoms came on, which, at first, were not
of an aggravated character, such as debility, and slight nausea
every morning, not amounting to vomiting. Then, daily rigors
set in, followed by fever, which ended in sweating, as in ordinary
intermittent fever. The periodical symptoms were stopped by
quinine, but he grew weaker, and at length died. Latterly, there
was some tenderness over the liver, which seemed enlarged.
The liver was found enlarged, but it presented no marked change
of structure except in the mucous membrano of the gall- ducts,
which was thickened and softened, and readily separable from the
tissue beneath it. The ducts were enlarged, and filled with pus,
and this through the entire organ, so that wherever an incision
was made, pus oozed out. The veins were particularly examined,
and were found healthy. The gall-bladder was full of bile, mixed
with pus. The mucous membrane of the entire alimentary canal
152
INFLAMMATION OF THE
was healthy. The other viscera of the great cavities appeared
perfectly sound. (Athenteum, Aug. 26-, 1843.)
In this case, no mention is made of jaundice, and the ducts do
not appear to have been completely obstructed. It seems, however,
that now and then, in catarrhal or suppurative inflammation of the
hepatic ducts, many of the small ducts become temporarily blocked
up at some point, and the portion behind gets dilated into an
irregular pouch, which is filled with a glairy or purulent fluid,
more or less tinged with bile. This happened in the following
case, which I have taken from Cm veil bier (liv. xl. pi. 1), and, on
account of the rarity of the disease, have given at length.
Case. Dull pain in the region of the liver, of long continuance — Jaundice —
Death from exhaustion — Marks of old inflammation of the surface of the
liver — Obliteration of the cystic duct — Narrowing of the lower end of the
common duct, which contained a gall-stone — General dilatation of the hepatic
ducts— Partial dilatation of many of the small ducts into irregular cavities,
filled with a puriform mucus tinged with bile.
A woman, 45 years of age, living in service, entered “La Cliarite,” the
9th of May, 1840, for a bronze jaundice of ten days date. The jaundice was
attended with fever; the pulse 108. There was no pain or tenderness in the
region of the liver, and no enlargement of the liver could be detected.
The following additional particulars were noted.
Catamenia, regular. Has never had a child. Thirteen years ago, was
struck v ith palsy of the right side, and a long time elapsed before this com-
pletely disappeared. Has long been subject to dull pain in the right hypo-
chondrium, which she has been accustomed to relieve by poultices. Has never
had colic, vomiting, or even nausea. The 20th of March last was jaundiced
for the first time. The jaundice went off at the end of twelve days, and re-
curred only ten days ago.
She was cupped to f gvj. over the liver, and ordered poultices, baths, enemas,
and lemonade.
The feverishness passed off, and was succeeded by a sense of extreme
weakness. There was no swelling in the region of the liver : and no pain,
even on firm pressure.
The following days, she seemed to be mending. Tire jaundice had almost
disappeared, and her appetite and strength were beginning to return, when,
the 28tli of May, a general illness came on with irritative cough, a frequent,
small pulse, continual desire to make water, pains in the region of the liver,
— and the jaundice recurred.
Leeches, baths, poultices, &c., mitigated the symptoms, and took away the
pain.
On the 6th of June, the jaundice was less, but there was prostration, with
HEPATIC DUCTS.
153
aphtha; of the mouth, loss of appetite, and general uneasiness. The frequency
of pulse continued. She had no pain, and the liver was not enlarged. (Whey;
with tartrate of potash.) Copious stools.
On the 8th of June, a little fluid was detected in the peritoneum, and the
belly was tender.
The 14th of June, for the first time, vomiting ; stools, involuntary.
The following days, exhaustion increasing from day to day ; inability to
move ; sloughs at the sacrum ; oedema, beginning at the legs, and becom-
ing general; cries from pain during the night.
She retained consciousness up to her death, which took place the 3rd of
July, fifty-five days after her admission to the hospital. There was no dis-
order of the brain until the evening before death, when she wonld not
answer questions, and could only be made to put out her tongue.
On examining the body, about two quarts of greenish serum were found
in the cavity of the peritoneum. No peritonitis, but some vascular fringes
on the colon in the iliac fossa.
The liver was of natural size, and of an olive colour. It was firmly united
to the diaphragm ; and its under surface about the gall-bladder was equally
firmly united to the arch of the colon and the upper part of the duodenum,
so that it required a long time to dissect out the gall-bladder, which formed
a very small cyst, with excessively thick coats, filled with greenish mucus,
and not communicating with the gall-ducts.
A section of the liver presented a ground of deep olive, with here and
there small irregular cavities, containing a thick purulent mucus, of various
colours, from orange-yellow to deep green. (There were thousands of such
cavities, which were distributed unequally through the liver, the chief seat of
them being the right lobe.) The substance of the liver about the cavities
did not appear inflamed. Some of these cavities seemed formed of a very
small gall-duct dilated ; others, of such a duct dilated and perforated ; others
again, of many such ducts dilated and perforated, and communicating, so as
to form sacculated pouches.
The common duct, contracted at its duodenal end, was dilated imme-
diately above, where there was a calculus which did not completely close
the canal. The dilatation extended to the hepatic duct and all its branches.
Where the gall-stone lodged, there was sloughing of the inner membrane of
the common duct. At the level of the cystic duct, of which not a trace could
be found, the common duct communicated with a lateral cavity, whose sides
were in a state of slough.
The spleen was healthy.
Lungs, cedematous.
Brain. — White softening of the corpus striatum, and of the adjacent con-
volutions. In the corpus striatum was a yellowish grey cicatrice, the remains
of the injury which caused the former hemiplegia.
Here, there were marks of former inflammation about the liver —
154
INFLAMMATION OF THE
firm adhesions between the liver and adjacent organs, obliteration
of the cystic duct, narrowing of the duodenal end of the common
duct. These changes sufficiently accounted for the dull pain the
patient had long suffered in the region of the liver.
The narrowing of the end of tho common duct, and the lodge-
ment of the gall-stone in it, evidently produced the general dilata-
tion of the hepatic ducts, and also produced the first attack of
jaundice.
The saccular distension of the small ducts resulted, most likely,
from inflammation of them. It is probable that, becoming
blocked up for a time at some point by the viscid secretion, the
portion above was subsequently dilated into an irregular pouch,
by the accumulation of purulent fluid, and by bile, which had no
longer any outlet.
The chief symptoms of this stage of the disease were jaundice,
occasional pain in the region of the liver, a quick pulse, with a
sense of general illness, and daily increasing weakness. At
length, nutrition became very much impaired ; there was sloughing
of the sacrum, sloughing of the gall-duct, white softening of the
brain — and the patient died of exhaustion.
It would seem that sacculated pouches, formed, as in this case,
by inflammation of the small hepatic ducts, may, by permanent
closure of the duct at the point of obstruction, be converted into
small permanent cysts, filled with a glairy fluid, more or less
tinged with bile. It is difficult to account in any other way for
the cysts of this character that are now and then found in the
liver.
Firm, white, nodulous tumors, surrounded by a distinct cyst, and
composed of a cheese-like substance, are also now and then found
in the liver, and are formed, I believe, in the same way. These
cysts are evidently situated in portal canals, and the cheese-like
substance of which they consist, contains in its middle a small
mass of concrete biliary matter, or has solid particles of biliary
matter diffused through it which can be seen by means of the mi-
croscope. There is usually a false membrane on the surface of the
liver at the points where these tumors reach it. In another chapter,
a fuller account will be given of these cheesy tubera, which have
been generally confounded with cancer. The cheesy matter is
very like that of a scrofulous gland, and is probably formed in the
same way, by inflammation of the mucous membrane, in these
portions of the ducts.
HEPATIC DUCTS.
155
These knotty tumors seem, indeed, to differ from the biliary
cysts before mentioned, only in the consistence of the matter
within the cyst — which varies according to the kind and degree of
the inflammation by which it is produced.
If a small gall-duct become obstructed in the same way by
thick, biliary matter, or otherwise, the portion behind may, per-
haps without inflammation at all, become dilatated into a small,
irregular, or sacculated cavity, containing mere mucus and bile.
Cruveilhier (liv. xii. pi. 4, fig. 3) has given a plate taken from a
specimen of this kind. A great number of cysts of various sizes
were scattered through the liver, some in its substance, others
rising above the surface, completely isolated from the gall-ducts,
but containing a deep yellow liquid. Tumors formed in this way
are perhaps generally multiple, and never attain a very large
size. The large, solitary, encysted tumors, containing a glairy
fluid, tinged with bile, which are now and then found in the liver,
are most probably hydatid cysts, (which in man are usually
single,) in which suppurative inflammation has been set up by
the entrance of bile. The greenish glairy fluid may be formed by
the mixture of bile and pus.
The irregular cysts, formed by dilatation of the small gall- ducts,
when they contain merely a thin mucous fluid mixed with bile,
may contract from absorption of the watery part of their contents,
and the cyst may at length close upon a small mass of concrete
mucus and bile.
Cruveilhier (liv. xii. pi. 4, fig. 2) has given a beautiful plate of
the liver of an infant, from five to six months old, which had
scattered through it a great number of small irregular cavities, the
largest the size of a small pea, with thick firm parietes, and contain-
ing concrete bile. It was, he says, almost impossible to trace the
continuity of these cysts with the gall-ducts. Besides the cysts,
the liver contained many small scattered masses of fibrous texture,
(perhaps like the cheesy tumors which have just been described,)
which Cruveilhier supposes to have resulted from the obliteration
of cysts.
The infant had tubercles in the lungs, and these cysts and small
fibrous masses in the liver were, at first, taken for tubercles. Cru-
veilhier states that he has found small cysts in the liver, contain-
ing solid biliary matter, twice in infants, and many times in
156
INFLAMMATION OF THE
adults. Ide supposes the cyst to be formed by dilatation of the
extremity of a gall- duct, and to become isolated from the ducts by
adhesive inflammation.
Marks of inflammation and other disease, are, as already
stated, much more common in the gall-bladder, and in the cystic
and common ducts, than in the hepatic ducts.
Inflammation of the mucous membrane may be confined to the
lower part of the common duct, or to the gall-bladder ; or it may
commence in the gall-bladder, and extend down the cystic and
common ducts.
The best example I have met with of acute inflammation of the
mucous membrane of the common duct only, is in the following
case recorded by Andral.
Case. Over-indulgence at table — Pain at the right of the epigastrium —
Jaundice — A pear-shaped tumor, not painful, in the situation of the gall-
bladder— On the eleventh day, sudden accession of severe pain in the region
of the liver, soon spreading all over the belly — Speedy collapse — Death the
next day — Inner surf ace of the duodenum intensely red — Coats of the common
duct thickened and easily torn, and its canal almost closed — Perforation of
the hepatic duct — A puriform liquid in the peritoneum — No other marks of
disease.
A shoemaker, 35 years of age, was admitted into La Charite, the 8th of
November, 1821. Six days before, after over-indulgence at table, he was
taken with sharp pain at the right of the epigastrium, a little below the edge
of the ribs. The next day, he remarked that his skin was yellow. On the
9th of November, the seventh day of illness, the conjunctiva and the entire
surface of the body had a yellow tint, and there was a dull pain in the right
hypochondrium. Below the cartilage of the eleventh rib, a pear-shaped
tumor was felt, the broad end of which extended a little below the umbili-
cus, while the narrow end was lost behind the ribs. This tumor, which was
supposed to be the gall -bladder distended, was moveable under the finger,
and not tender.
The tongue was natural. The patient had some thirst ; no appetite. The
bowels moved seldom ; the stools were not coloured with bile. The pulse
was quick ; the skin hot and dry. (Leeches to the anus ; whey, with acetate
of potash ; diet.)
The four following days, the tumor grew larger, but no other change took
place. On the 13th of November, the eleventh day from his first feeling the
pain in the side, the patient was seized, all at once, with a much more severe
pain, which, starting from the region of the liver, soon spread over the whole
belly.
COMMON DUCT.
157
The pain continued extremely severe, and was much increased by the slight-
est pressure ; the features became pinched, the pulse small and very frequent,
and the extremities cold j and the patient died in the afternoon of the next
day.
The sac of the peritoneum was filled by a puriform liquid, everywhere
yellow, hut much more so in the right flank than in other parts. The inner
surface of the duodenum was intensely red. The entrance of the common
duct was marked by a small round tumor, rising three lines above the surface
of the intestine, and pierced at its summit by a capillary orifice, the opening
of the duct. The coats of the common duct were much thickened and easily
torn, and the canal almost closed.
The hepatic and the cystic ducts, and the gall-bladder, were dilated. In
the hepatic duct, just above its junction with the cystic, was a perforation,
having an irregular, roundish outline, and large enough for the passage of a
small pea. Around the perforation, the texture of the coats of the duct did
not seem altered. The tissue of the liver exhibited nothing remarkable. In
the stomach were some spots in which the mucous membrane was red. The
rest of the alimentary canal, and the other organs, seemed healthy. — (Clin.
Med. t. iv. p. 495.)
This case seems to have been an instance of acute inflammation
of the duodenum and of the common duct, caused by over-indulgence
at table. The symptoms were pain in the situation of the inflamed
duct, soon followed by jaundice and by dilatation of the gall-
bladder ; loss of appetite, thirst, fever. The disease had lasted
eleven days, when rupture of the hepatic duct took place, causing
peritonitis and rapid collapse.
The inflammation does not seem to have extended above the
common duct. The distended gall-bladder was not painful or
tender ; and the coats of the hepatic duct about the perforation,
were not sensibly altered in texture.
The early jaundice, and the distension of the gall-bladder, were
the effect of closure of the common duct, by thickening of its
mucous coat. The gall ducts, from their small diameter, must he
completely closed by a very slight thickening of their coats.
Andral gives another case, (Id. p. 499,) which did not prove
fatal, but which, judging from the symptoms, was of the same kind.
In the summer of 1824, a man, about 30 years of age, felt severe pain in
the right hypochondrium for two days, and then became jaundiced. When
he entered the hospital, the jaundice and the pain were still present ; and
immediately below the cartilages of the false ribs, was a moveable, pear-
158
INFLAMMATION OF THE
shaped tumor, which Andral took for a distended gall-bladder. The pulse
was quick, the skin hot, the bowels obstinately hound. (Twenty leeches to
the anus; enemata; foot-baths; barley-water.) The next day, the fever
ceased. During the three following days, the tumor grew less, and then dis-
appeared together with the pain. The jaundice went off, the constipation
ceased, and the patient soon left the hospital well.
There can he little doubt, that this case, like the former, was
one of acute inflammation of the common duct, not extending to
the gall-bladder. The symptoms in these cases were just what
might have been expected : pain in the situation of the duct,
followed, at the end of one or two days, by jaundice and by dis-
tension of the gall-bladder ; a certain degree of fever ; constipa-
tion. It is worthy of remark that in neither case does Andral
notice among the symptoms, vomiting, or nausea, or rigors.
It is probable that similar cases now and then occur, and are
treated as inflammatory jaundice, without their real nature being
discovered. The symptoms differ from those of ordinary cases of
jaundice, chiefly in the pain being limited to a small spot in the
situation of the common duct, and in the early appearance of a
large, moveable, pear-shaped tumor, not painful or tender, which
may be recognised by these characteristics as the gall-bladder
distended from closure of the common duct. The absence of
pain or tenderness of the tumor, shows that the gall-bladder is not
inflamed.
If the inflammation should involve the cystic and hepatic ducts,
as well as the common duct, distension of the gall-bladder would
perhaps not take place, and the symptoms would he merely those
of inflammatory jaundice.
But inflammation may commence in the mucous membrane of
the gall-bladder, and for some time may not extend to the ducts.
The following case related by Dr. Graves, in his recent work on
Clinical Medicine, (p. 463) is a very striking instance of catarrhal
or plastic inflammation, at first confined to the gall-bladder.
Case. — “Ann Milton, a healthy fine young woman, aged 20, (servant,)
admitted into the Meath Hospital, under Dr. Graves, November 1st, 1S41.
About five weeks ago was attacked with pain in the right hypochondrium,
extending into the epigastrium, which lasted for a fortnight, and was followed
by jaundice and high-coloured condition of the urine. She does not recol-
lect whether the feces were whiter than usual. After the skin got yellow
GALL-BLADDER.
159
the pain in the side diminished ; but during the whole time it lasted she had
constant vomiting and nausea. Three days after the setting in of pain, and
ten before the appearance of the jaundice, she became affected with excessive
itching of the skin, which prevented sleep; this itching ceased as soon as the
jaundice appeared. She had no pain in either shoulder. At the time the
skin became yellow, an eruption of an herpetic character appeared over the
hepatic region. She was under no treatment for the pain ; but to the
eruption, a mixture of gunpowder and blood was applied.
Present symptoms. — Skin and conjunctiva? deeply jaundiced; all objects
appear yellow ; urine high-coloured ; faeces white; no itching of the skin;
the linen over the eruption is stained yellow ; tongue clean and moist ;
great thirst ; appetite good ; stomach not sick ; no pain after taking meals ;
bowels confined; sleeps badly; no headache; pulse 80, full and soft;
breathing hurried ; no cough or physical sign of disease in either lung ; the
heart’s action strong, but the sounds are normal and distinct; complains of
no pain when the right hypochondrium is pressed, or when the ribs are
pushed against the liver, hut she has a slight pain at a point between the
right hypochondrium and epigastrium, greatly increased by pressure. There
is some fulness of the latter region, but percussion does not give a dull
sound ; no enlargement of the liver noticeable or detected by percussion ;
the abdominal muscles are very irritable, and are thrown into spasm by the
least effort to examine the abdomen minutely ; she has no pain over either
lumbar region. Poultices to the eruption— twelve leeches to the painful
part. p.. Pil. hydrarg. gr. x. Pulv. Doveri gr. v. in pil. iij. St. j. 4tis horis.
Enema purgans.
Nov. 5th. — Pain relieved by leeches ; no other change ; appetite extremely
good.
Nov. 6th. — Was attacked last night with pain in the stomach ; no vomit-
ing; pulse to-day fuller and quicker — 100; breathing not hurried; ‘feels
unwell ’ to-day ; tongue clean ; some thirst ; appetite good ; bowels confined ;
skin dry ; no change in the jaundice ; complains of tenderness at the point
before mentioned.
R. Pil. hydrarg. gr. v. ter in die. Hirud. xij. P. D.
Nov. 7th. — On the previous evening she became delirious, and this morn-
ing, (7th,) at the hour of visit, was quite comatose, and soon after died.
Post' mortem. — The brain and abdominal viscera were the only parts ex-
amined. The liver was not by any means enlarged, and a section of it dis-
closed no excess of blood. It was of a light brown colour, tinged with
yellow, as if from a superabundance of the colouring matter of the bile.
The gall-bladder was distended, and on being opened, was found completely
filled by a dark green mass of a tenaceous viscid nature, apparently lymph.
This substance was of the same pyriform shape as the gall-bladder, and
terminated by its narrow extremity at the commencement of the gall-duct.
On its removal, the fining membrane of the gall-bladder presented a bright
scarlet colour and villous appearance, and the natural and beautiful ‘ honey-
comb ’ arrangement of the mucous membrane was completely effaced- There
6
160
INFLAMMATION OF THE
was no softening or ulceration of the membrane, nor was the colour different
in any pai't. It resembled very much the appearance of the mucous mem-
brane in acute laryngitis. The walls of the gall-bladder were much thickened.
There was no obstruction in the ductus choledochus, the cystic or hepatic
ducts, and their lining membrane was quite free from any unusual vascularity :
the duodenum and stomach were stained with the colouring matter of the
bile, but in other respects were healthy ; no gall-stones or other obstruction ;
the kidneys were natural-
Cranium. — The dura mater was stained of a yellow colour; there was no
thickening or opacity of this membrane ; the arachnoid and pia mater were
quite healthy; the substance of the brain was firm and free from any
unusual vascularity ; no effusion of lymph in any part ; the ventricles were
not distended with fluid beyond what is normal, but the fluid, though in
small quantity, was of a yellow colour, and the surface of the different parts
contained in each ventricle, was also of a light yellow colour ; the nerves and
all other parts of the organ were free from this staining.”
In this case, the disease seems, for the first fortnight, to have
been confined to the gall-bladder, and, during that time, the chief
symptoms were pain and tenderness in the region of the gall-
bladder, with constant nausea and vomiting. Jaundice then came
on, and continued till the death of the patient. It is not clear,
whether the jaundice resulted from closure of the common or he-
patic duct from inflammation extending to them from the gall-
bladder, or from mere suppressed secretion of bile.
Suppurative inflammation of the mucous membrane of the
gall-bladder, now and then occurs in the course of typhoid fever.
M. Louis, in Iris elaborate work on Typhoid Fever, has given three
cases (Obs. 1, 11, & 28) in which he found a purulent fluid in
the gall-bladder, mixed with very unhealthy-looking reddish bile.
In one of these cases, (Ohs. 28,) the mucous membrane was a
little thickened ; hut in the others, it presented no other change
than slight redness. In not one of them did the gall-ducts ex-
hibit any marks of disease. The inflammation of the gall-bladder
was probably caused by bile, unhealthy when first secreted, and
rendered still more irritating by long retention in the bladder.
It gave rise to no symptoms that could be distinguished amidst
the general disorder of the fever.
Suppurative inflammation of the gall-bladder seems especially
liable to occur when, by any cause, the cystic duct is permanently
closed.
GALL-BLADDER.
161
Cruveilhier (liv. xxiii. pi. 5) has given a plate of a liver
studded with cancerous tumors, in which the cystic duct was ob-
literated, and the gall-bladder inflamed and full of pus. No notes
of the case are given.
A similar instance is recorded hy Andral, (Clin. Med. iv.
518,) in the case of a woman, who died at the age of 47.
There were were numerous cancerous tumors in the liver. The
gall-bladder was full of pus, and its mucous membrane in-
flamed. The cystic duct seems to have been closed. The hepatic
duct was very large and full of bile. The common duct exhibited
nothing unusual. There was recently effused lymph on the surface
of the peritoneum, and the mucous membrane in the large end of
the stomach was softened. No other marks of disease are noticed.
Some cases to be related farther on render it probable that in
these instances the suppurative inflammation of the gall-bladder
resulted, in part at least, from closure of the cystic duct, and the
consequent long retention of bile, which from being, at first, mor-
bid, was rendered still more irritating hy becoming concentrated,
and perhaps also decomposed.
Inflammation of the gall-bladder, whether catarrhal or suppu-
rative, seldom perhaps proves fatal of itself, except when the cystic
duct is closed, and the gall-bladder converted into an abscess.
When it is the sole disease, and the ducts are open, so that the
matter can escape, the patient may perhaps recover perfectly, or
may survive with the gall-bladder more or less changed in struc-
ture. 1 have twice found the gall-bladder and cystic duct con-
tracted, and their coats thickened, in young persons who died of
other diseases, and in whom there were no gall-stones, nor any
trace of inflammation of the common or hepatic ducts, or of the
capsule or substance of the liver.
I refrain from giving any details of these cases, as no particu-
lars were noted that can serve to mark even the date of the dis-
ease of the gall-bladder.
Occasionally, the coats of the common duct, as well as those of
the gall-bladder and cystic duct, are found thickened and indurated,
without gall-stones, or trace of inflammation in other tissues of
the liver. It is probable that in most cases of this kind inflamma-
tion is set up first in the gall-bladder by long retention of irritat-
M
162
INFLAMMATION OF THE GALL-BLADDER.
ing bile, and afterwards in the ducts by the passage of this together
with irritating secretions from the bladder.
In persons dead of granular liver, with ascites, it is not very
uncommon to find the gall-bladder and cystic duct much con-
tracted, and their coats thickened and indurated. The canal of
the duct is much narrowed, and now and then completely closed,
so that the duct is transformed into a fibrous cord. When this is
the case, the gall-bladder contains yellowish mucus, or is moulded
on a gall-stone, formed of mucus and the yellow matter of the
bile. In these Oases, I imagine, the gall-bladder and cystic duct
become inflamed, secondarily, like the capsule of the liver.
(Clin. Med. iv. ohs. 51 and 52.) The inflammation is probably
seated in the outer coats. From there being other disease of the
liver, it is difficult to determine in what degree the symptoms de-
pend on disease of the gall-bladder and duct.
Sometimes the coats of the common duct, as well as those of
the cystic, are thickened and indurated, and the canal much con-
tracted. In such cases the hepatic duct and its branches are
found dilated and filled with thick yellow bile ; and the tissue of
the liver is greenish or olive. (Clin. Med. iv. ohs. 49, 50.)
When the common duct is much obstructed, there is a deeper
jaundice than belongs to mere cirrhosis. The colour of the skin
is a golden yellow shading into green.
Further on, more ample details will he given of the effects of per-
manent closure of the common duct, which may result from various
causes besides inflammation, and is very important, because it
suspends the office of the entire liver, and, in the end, completely
destroys the cells by which the bile is secreted.
Another, and much more common cause of inflammation of the
gall-bladder, and of the cystic and common ducts, at least among the
rich, is the mechanical irritation of gall-stones. But this gives
rise to ulceration, rather than to the diffuse catarrhal or suppura-
tive inflammation we have hitherto chiefly considered.
Croupal or plastic inflammation of the mucous membrane of
the gall-bladder and ducts is very rare. Rokitansky says he has
observed it in the ducts within the liver, in what has been called
ULCERATION OF THE GALL-BLADDER.
163
the secondary fever of cholera, and as a sequel of ordinary typhoid
fever. It produces within the gall-ducts membranous tubes, in
which the bile forms tree-like concretions ; and this again, by
blocking up the passage, causes distension of the capillary ducts
behind.
Ulcerative Inflammation of the Gall-bladder and Ducts.
Ulceration of the gall-bladder is much more common than the
forms of inflammation yet considered, and occurs in various cir-
cumstances.
It has been noticed by more than one observer, among the
morbid appearances of remittent fever.
Sir Gr. Blane, in bis account of the Walcheren fever, states that
the mucous membrane of the gall-bladder was frequently found
inflamed and ulcerated ; the ulcers having in some cases the coni-
cal or tubercular form sometimes seen in dysentery. The gall-
bladder was generally distended with bile, which, in those persons
who died early, was of a deep green or dark brown, but in more
protracted cases had the consistence and the colour of tar. This
tar-like fluid did not taste bitter like bile, and when mixed with
water did not impart any yellowness to it, while it was often
so acrid as to excoriate the lip. (Williams’ Morbid Poisons,
vol. ii. p. 470.)
Mr. Boyle, speaking of the Sierra Leone fever, says there were
in almost all cases traces of inflammation in the pyloric extremity
of the stomach, extending thence along the duodenum to the
entrance of the gall-duct, about which, for the space of a Spanish
dollar, the inflammation seemed to have attained the greatest
height. The duct was ordinarily choked by dark-coloured, viscid
bile. The gall-bladder was probably not examined. The other
abdominal viscera are stated to have been congested, but otherwise
healthy. (Id. p. 478.)
In the yellow fever at Barcelona, in 1821, there were usually
traces of inflammation of the stomach, small intestine, and
duodenum, not unfrequently extending to the gall-bladder.
(Id. p, 473.)
The acrid quality of the bile in the Walcheren fever, and the
circumstance that in Dr. Boyle’s dissections, the strongest marks
of inflammation in the intestinal canal were about the entrance of
M 2
164
ULCERATION OF THE GALL-BLADDER.
the common cluct into the duodenum, render it probable that the
inflammation of the gall-bladder and duodenum, in remittent
fever, is caused by irritating bile. As in typhoid fever, the symptoms
of inflammation of the gall-bladder are not distinguishable in the
midst of thegeneral disorder that constitutes the fever, and the symp-
toms of inflammation of other parts that likewise occur in its course.
In this country, ulceration of the gall-bladder is produced per-
haps not unfrequently by the irritation of gall stones.
Ulceration of the gall-bladder and gall stones are often found
together, but we must not infer, in all such cases, that the ulcers
were produced by the gall-stones. Both the ulcers and the gall-
stones may have resulted from the presence of bile of unnatural
quality.
When there is only one ulcer in the bladder, and a large
or hard gall-stone is found resting upon it, we may perhaps
safely infer that the mechanical irritation of the gall-stone was the
cause of the ulcer. Gall-stones too large to pass through the
cystic duct, not unfrequently cause ulceration of the lower or de-
pending part of the gall-bladder ; lymph is poured out on the
peritoneal coat below the ulcer ; the gall-bladder becomes united
by this means to the duodenum or colon ; the ulcer eats like-
wise through the coats of the intestine, at this point ; and the
gall-stone escapes into the intestinal canal. The processes of ul-
ceration and adhesion take place very slowly, and are seldom
attended by alarming symptoms. Often, indeed, the first clear
intimation that such an event has happened, is the discharge of a
large gall-stone from the bowels.
In other cases, we find many small round ulcers in the gall-
bladder, and perhaps in the common duct, and small gall-stones
in the bladder not resting on the ulcers. When it is considered
that most human gall-stones are so light as to float in bile — since
they almost float in water, which is of much lower specific gravity
— aud that, consequently, they can exert no pressure on the coats
of the gall-bladder from their weight, when there is bile enough in
the bladder to keep them afloat ; — it seems most reasonable to refer
both ulcers and gall-stones in these cases to an unhealthy state of
the bile.
Further on, I shall relate a case recorded by Dance, where,
without gall-stones, there were not only numerous ulcers of this
CAUSES.
1G5
kind in the gall-bladder and common duct, but also four or five
small deep ulcers in the duodenum, in the space of a crown-piece
around the mouth of the common duct, while the rest of the in-
testines was healthy. One can hardly avoid the inference, in such
a case, that the ulceration was caused by irritating bile.
Ulceration of the gall-bladder seems especially liable to occur,
in persons in whom the gall-bladder has suffered from former
disease. The following case, which fell under my care in 1837,
affords an instance of this.
John Sibston, set. 18, a collier, was admitted into the Dreadnought the
21st September, 1837, on account of vomiting of blood, which had come on
that morning. He stated that he was quite well previously.
During the 21st, he suffered great pain at the epigastrium, vomited blood
several times, and had several loose stools.
Eighteen leeches were applied to the epigastrium, and he was ordered di-
lute sulphuric acid, mvij. every four hours.
On the 22nd, he did not vomit. He was bled from the arm to Jviij., and
xij. leeches were applied to the epigastrium.
On the 23rd — the first time I saw him — the skin was hotter than natural :
the pulse 100. There was still tenderness, and some tension, at the epigas-
trium. The tongue had a yellowish paste on its middle, but was red at the
edges ; no appetite ; thirst ; had vomited once this morning, but no blood ;
had slept tolerably. The blood drawn yesterday, not buffed or cupped. He
was put on fever-diet ; and the sulphuric acid was continued.
25th. Epigastrium still tender; skin hot; pulse 90; less thirst; a white
coat on the tongue. No vomiting since the morning of the 23rd ; bowels
rather confined. The sulphuric acid was left off, and common effervescing
draughts were given, instead.
26th. Tenderness of epigastrium has ceased ; no vomiting : bowels con-
fined ; some appetite ; no thirst; has slept well. A dose of salts and senna
was given ; and the effervescing draughts were continued.
28th. No vomiting; bowels rather confined; appetite good : sleeps well.
Beef tea, Oij.
On the 4th of October, he was put on meat diet.
He continued on this diet, walking about the wards, seemingly in full con-
valescence, (his appetite good, bowels regular, sleep sound,) until the even-
ing of the 10th of October, when he was taken with malignant cholera. He
soon fell into a state of collapse, and died early in the morning of the 1 2th.
At that time cholera prevailed in the Dreadnought. Twenty- one of the
patients fell ill of it in the course of three weeks.
The body was examined ten hours after death.
The cardiac extremity of the stomach was united to the under surface of
166
ULCERATION OF THE GALL-BLADDER.
the left lobe of the liver by a false membrane, in which were some chalky
bodies, the size of small peas. The pyloric end of the stomach, and the
colon, were firmly united to the gall-bladder, whose coats were much
thickened.
The gall-bladder contained some pus, and its mucous membrane was exten-
sively ulcerated. On the surface in contact with the fiver, there was an ulcer
as large as a shilling, and several smaller ones. On the opposite surface,
there were some very small circular ulcers, scarcely larger than pins’ heads.
The ulcers had eaten through the mucous coat. There were no gall-stones.
The tissue of the fiver appeared healthy.
The mucous membrane of the stomach in its splenic extremity was soft
and thin, and red from the injection of small vessels, visible to the naked eye.
The rest of the intestinal canal presented only the appearances usual in per-
sons dead of cholera. The mesenteric glands were enlarged. In the trans-
verse meso-colon were many bodies, about the size of a hazel-nut, composed
of matter resembling soft cheese or glazier’s putty, in a very distinct capsule.
The spleen was firmer than usual, but of the usual size. The left lung was
united to the pleura costalis by old tissue ; the right lung was free. Both
lungs were healthy.
The heart and the kidneys were sound. There were yellow fibrinous
clots in the right auricle and ventricle, but none in the left chambers of the
heart.
In this case, inflammation of the gall-bladder seems to have
come on in the midst of apparent health. The symptoms at first
were, vomiting of blood, which recurred several times ; severe
pain, with tenderness, and some tension, at the epigastrium ; some
fever, with loss of appetite, thirst, and a foul tongue. These
symptoms passed off in a few days, and the patient seemed con-
valescent, when he fell ill of malignant cholera, of which he soon
died. The case shows that there may be extensive ulceration of
the gall-bladder without any special symptoms to denote it. For a
fortnight before the attack of cholera, there was no pain or tender-
ness at the epigastrium, and no vomiting, although there can he
little doubt that the ulcers of the gall-bladder then existed.
In the following case, which I have taken from Cruveilhier,
(liv. xxix.) inflammation and ulceration likewise occurred in a
gall-bladder previously diseased ; hut here there was an additional
cause for it in the cystic duct being closed by a gall-stone.
Madame Mazet, aet. 34, of very strong constitution, and very stout, sent for
Cruveilhier, the 11th September, 1837- She was suffering from extreme diffi-
culty of breathing, with pain in the hypochondria, especially the right. She
CAUSES.
167
complained, besides, of a sense of anguish and suffocation, and incessantly
begged that the window might be opened, and that vinegar might be given her
to inhale. She was sweating profusely, but her features were not changed.
M. Villeneuve had attended her for three days. The first day he applied
leeches to the epigastrium ; the second day, bled her from the arm ; the third
day, again applied leeches to the epigastrium.
In the moments of anguish, there was a sense of faintness and desire for
fresh air and vinegar, without change of the features or the pulse.
Poultices and sinapisms were ordered, in addition to the means before
prescribed.
The 12th and 13th, she continued in the same state. There was the same
feeling of anguish, the same sense of faintness.
A blister to the seat of pain, laxatives, and a bath, were ordered.
She walked down a flight of stairs to the bath, and up again, without
help.
In the morning of the 14th, she thought herself better, when she was taken
suddenly with violent shivering, soon followed by signs of peritonitis. In
the evening, the belly was tympanitic and tender, especially under the right
false ribs ; the pulse not perceptible ; the body bathed in sweat.
The morning of the 15th, the belly was still more tympanitic ; the pulse,
miserable, thready. At her own solicitation, she was bled from the arm. The
bleeding was followed by long syncope. The blood was very much buffed.
She died in the night.
There were the usual marks of suppurative inflammation of the peritoneum,
in the neighbourhood of the liver. The inflammation had been limited to
this part of the peritoneum, by adhesions formed by coagulable lymph. The
gall-bladder was collapsed, and almost empty. Its coats were very much
thickened, and its neck was blocked up by a calculus of cholesterine, which
completely isolated it from the ducts, and which no doubt had existed a long
time. The disease was inflammation of the mucous membrane of the gall-
bladder, which had involved the entire thickness of its coats.
The mucous membrane was perforated, and the peritoneal coat torn, rather
than ulcerated, at a point which did not correspond to the perforation of the
mucous membrane. The pus consequently oozed from the gall-bladder — a
circumstance which accounts for the inflammation of the peritoneum being
limited to the neighbourhood of the liver.
In this case, the early history of the disease is not given. The
severe symptoms the patient suffered when first seen by Cruveil-
hier, were probably consequent on rupture of the gall-bladder.
The following case, which I have taken from Andral, (Clin.
Med. t. iv. p. 500,) affords another instance of the same kind.
Case. — Vomiting, followed by profuse diarrhoea and jaundice — No appetite —
Difficult digestion — Sense of weight and heat at the epigastrium— Great loss
168
ULCERATION OF THE GALL-BLADDER.
of flesh — At the end of about three months and a half, symptoms of periton is
from perforation — Death the following night — Perforation of the gall-
bladder— Coats of the gall-bladder everywhere easily torn — Canal of the
cystic and common ducts much narrowed by thickening of their coats — Dila-
tation of the hepatic duct.
A porter, ( un fort a la Halle ) aet. 64, entered La Charite' In the latter half of
December, 1821. Three months before, he was taken, without known cause,
with bilious vomiting, which lasted several days. The vomiting ceased, and
was succeeded by profuse diarrhoea, which continued about a month, and
weakened him much. About the middle of September, the diarrhoea abated,
but he did not regain strength. He had hardly any appetite, and his di-
gestion was difficult. He then perceived that his eyes and skin had a well-
marked yellow tint. Although he lost flesh and strength daily, he continued
to labour until eight days before his admission to the hospital.
At the time of admission, he was much emaciated, and his skin had a
yellow tint, shading into green. His tongue was nearly natural, but he had
no appetite, and what little food he ate caused a sense of weight and heat at
the epigastrium, which lasted several hours. The bowels were confined ;
the stools ash-coloured. No tumor could be discovered in the abdomen,
which was everywhere soft and nowhere tender. The pulse, in the morning
and during the day, was not quicker than natural, but increased a little in
frequency in the evening.
Leeches were applied to the epigastrium : afterwards, a blister. His sole
nourishment was milk and broth.
A fortnight after his admission, the stomach seemed better ; the febrile
movement in the evening was much less marked ; but the jaundice continued;
he did not recover strength, and the emaciation increased.
One morning, when in the act of sitting up, he felt all at once as though
something had burst in the right hypochondrium. This was succeeded by
symptoms of peritonitis from perforation, and he died the following night.
A large quantity of dirty grey liquid and some membranous flakes of lymph
were found in the cavity of the peritoneum. There was no perforation of the
stomach or intestines.
The gall-bladder, which was very small, presented on its lower surface,
not far from its broad end, an opening as large as a “ five-sous ” piece. The
inside of the gall-bladder presented nothing remarkable, but its coats were
everywhere easily torn.
The canal of the cystic and common ducts was so narrowed by thickening
of their coats as not to admit the smallest probe. The hepatic duct, on the
contrary, was much dilated, and was filled by solid biliary matter. The
tissue of the liver was not appreciably changed.
The mucous membrane of the stomach in all its extent was much
thickened, and mammellated, ar.d of a grey slate colour. The submucous
areolar tissue and the muscular coat were also thickened. The slate colour
of the stomach was continued into the duodenum. The rest of the intestinal
CAUSES.
1G9
canal presented no appreciable change. There was nothing worthy of remark
in the other viscera of the three cavities, except a very striking yellow colour
of the dura mater.
In this case, there had been inflammation of the gall-hlaclder
and of the cystic and common ducts, which had much changed the
texture of the gall-bladder, and almost obliterated the ducts.
The circumstance that the vomiting and diarrhoea preceded the
jaundice, renders it probable that the disease began at the gall-
bladder, and that the ducts became inflamed subsequently ;
probably by the passage of irritating matter through them. The
perforation of the gall-bladder, which, by setting up peritonitis,
caused death so speedily, might have resulted from mere defective
nutrition of its tissues. The symptoms which preceded this
perforation — the sense of weight and heat at the epigastrium, the
loss of appetite, the difficult digestion, the progressive emaciation,
the deep jaundice, without any enlargement of the liver, — are fully
explained by the state of the gall-bladder, and the almost complete
closure of the common duct.
The case affords a good example of inflammation confined to
the gall-bladder, and the ducts by which it empties itself, occur-
ring without gall-stones or other disease of the liver.
In the following case, for which I am indebted to Mr. Bowman,
ulceration and sloughing of the gall-bladder, occurred during
typhoid fever. The coats of the gall-bladder were thickened by
previous disease, and the cystic duct obliterated.
Case. September 17th, 1835.— Ann Burnacle, aet. 16, rather fat, a
housemaid, was admitted to-day in a state of delirium. Whole body cold ;
countenance, pale and anxious ; pulse, quick and feeble ; tongue, foul, moist ;
urine, scanty, rather high-coloured ; has just had two ocliery stools ; thirst
very considerable ; when the abdomen is pressed she evidently suffers a good
deal of pain ; headache ; is constantly getting out of bed and hiding the
chamber utensils ; muttering delirium ; cannot be made to answer questions,
or even to tell her name ; movements tremulous.
Her friends report that on Saturday last (the 12th) she was seized with
chills and afterwards heat, accompanied with headache and general soreness.
She became delirious two days ago. Has had no medical advice.
Lemonade, and fomentations to the belly were ordered.
No notes of her state from this time were taken, except that she had severe
purging. She died on the 24th. The following treatment was adopted.
Sept. 18th.— Hyd. c. creta. gr. v. pulv. ipecac, co. gr. iij. ter die. Mist,
camph. f. 3j. 4tis horis. Empl. lyttfe unchse.
170
ULCERATION OF THE GALL-BLADDER.
Sept. 19th. — Empl. lyttae abdomini.
Sept. 21th. — Hyd. c. creta. gr. v., P. cretae c. opio 9ss nocte maneque su-
mend. ; quiniae sulph. gr. j. ter die.
Sept. 23rd — An egg ; port wine.
Sectio cadaveris, twenty-six hours after death.
Head. — Some effusion beneath the arachnoid, on the surface of the hemi-
spheres, and at the base of the brain. No morbid appearance in the brain
itself, nor any effusion into the ventricles.
Chest. — Congestion in the depending parts of the lungs. Slight redness of
the mucous membrane of the air-passages, which contained a good deal of
frothy mucus. Heart natural-
Abdomen. — Mesenteric glands deeply injected. The lower part of the
ileum was of a deep mahogany colour, and, on slitting it open, several large
sloughy ulcers of a brownish-green were discovered. The last three or four
inches were occupied by one large ulcer, in which the mucous membrane
was completely destroyed, a few shreds of it only remaining, and causing
great raggedness of the surface. It was of a dark dirty green colour. The
muscular coat beneath was considerably thickened, but nowhere destroyed.
The mucous membrane around the sloughs was of a deep purple, thickened,
and rather soft.
The glands of the colon were enlarged and ulcerated, chiefly near the sacrum.
The stomach was large, and distended by a green fluid, similar to some
vomited by the patient the night before her death. There were clusters of
bright red points or dots along its large curvature, but there was no soften-
ing of the mucous membrane.
The gall-bladder was rather large, and filled with a watery fluid of the
colour of weak tea. On the outside, it was of a lightish colour, and neither
it nor the adjacent viscera were tinged, as is usual, by transudation of
bile. In one part, however, it was red, and in the centre of this portion
there were sloughs- The largest of these, about the size of a fourpenny-piece,
was situated on the attached surface of the bladder, others on the free convex
surface. They all extended through the different coats, but the mucous mem-
brane was destroyed in greater extent than the others. The sloughs appeared
recent, were surrounded by marks of inflammation, but no commencement of
the process of separation was perceptible. A small quantity of recently effused
lymph was attached in flakes to the outer surface of the gall-bladder and
the adjacent surface of the liver, but, in the latter situation, more sparingly.
The cavity of the gall-bladder was found to be divided into two almost dis-
tinct sacs, separated from one another by a semilunar fold of the lining
membrane, which was situated about two- thirds of the whole length from the
fundus. On either side this transverse fold, the gall-bladder was dilated,
the communication between the cavities just admitting the little finger- The
sloughs, with the surrounding inflammation, were situated in the larger cavity,
while the smaller was of a bluish-white, and exhibited no trace of recent
morbid action. The mucous membrane of the gall-bladder was somewhat in-
durated and thickened, as though it had been the seat of previous disease.
6
CAUSES.
l/l
The cystic duct was obliterated by adhesion of its coats, at two or three
different points, for the distance of about two inches from the gall-bladder.
Beyond that portion, it was healthy, and coloured, as were the hepatic
and the common ducts, by healthy-looking bile.
In this case, the sloughing of the gall-bladder is perhaps attri-
butable to a general tendency to gangrene, as manifested in the
ulcers in the ileum ; and to the circumstance that the gall-bladder
had been damaged, and its nutrition impaired, by previous dis-
ease. As in the cases recorded by Louis, already alluded to,
in which suppurative inflammation of the gall-bladder occurred
during typhoid fever, there were no symptoms by which the
disease of the gall-bladder could be detected, amidst the general
disorder.
In the following case, for which I am also indebted to Mr.
Bowman, ulceration and sloughing of a gall-bladder not previously
diseased, came on immediately after the patient had received a
severe injury from the falling in of the sides of a sand-pit.
Case. — Compound fracture of the left leg, fracture of the right arm, and gene-
ral bruises — Two days after,' severe gnawing pain at the epigastrium and
right hypochondrium, increased by pressure — Nausea and vomiting — Appre-
hension of death — Death seven days after the accident — Lymph on the peri-
toneum covering the small intestines, the stomach, and the under surface of
the livei — Sloughing of the outer membrane of the gall-bladder in three or
four spots — Ulcers of the inner membrane not corresponding to the sloughs of
the outer.
Thomas Collins, set. 61, a thin old man, an agricultural labourer, of intem-
perate habits in his youth, but, by his own account, sober of late years, was
brought into the hospital, (Birmingham,) at four p. m., on the 22nd of De-
cember, 1834, under Mr. Hodgson.
A few hours before, he was at work in a sand-pit, when several tons of sand
fell in, threw him on his face, and covered him. He was dug out, and
brought to the hospital.
Besides general bruises, there was a compound fracture of the lower third
of the left leg. The fractured ends of the tibia had protruded through the
skin in front, by two small triangular openings, from which there was a
constant oozing of venous blood. In addition to this injury, the radius of
the right arm was fractured near the wrist.
The limbs were bandaged in the usual manner.
Dec. 23rd. — Has passed a sleepless night, in great pain, chiefly in the arm
and leg, and complains of general soreness ; bowels not open.
172
ULCERATION OF THE GALL-BLADDER.
R. Liq. opii. sedativ. mxxv. statim et repet. Lora somni si opus sit.
Dec- 24th. — (Morning.) Was restless the great part of last night. Omitted
taking the draught till four this morning, since which he has had some
sleep. Complains of great pain in the arm- The leg is easier. Bowels open
once; pulse 76, regular.
(Six, p. m.) — About noon he was seized with very severe ‘ gnawing’ pain at
the epigastrium and right hypochondrium, which continues. It appears to
he increased by pressure. He moans, and seems to he in great agony. His
tongue is dry, and he is thirsty. No delirium or headache, but great de-
pression of spirits, and apprehension of death.
Appl. hirud. x. epigast; postea, cataplasma. A glass of warm brandy and
water ; broths.
T. opii 3ss, sp. ammonise aromat. 5j. aq. menth. pip. 3j. post horas iij.
sumend. et repet. hora somni si opus sit.
Enema commune statim. c. sodse muriat. sss.
Dec. 25th. — Has had nausea during the night, and has vomited several
times. The fluid is bilious, and mixed with the (undigested) food he ate the
day he received the accident. The nausea continues ; eructations ; the pain
at the epigastrium is not quite so severe, but he moans almost constantly,
and suffers much from general pains. The leg is easy and lies well; there is
no swelling near the fracture- Pulse 76, soft; tongue dry and brown; bowels
open once.
Haust. salin. efferves. c. ammonise s. carb. 4tis horis. Broths.
Cal. gr. v. opii. gr. j. hora somni.
Dec. 26th. — Slept tolerably well. He lies quiet, but is constantly moaning
on account of the severity of the pain at the “ precordia,” which “ shoots
through him,” and is not much aggravated by pressure. He says he is
“ dreadful all over him.” There is great depression of countenance and fear
of approaching dissolution. Pulse 84, sluggish, exceedingly compressible.
He has vomited a large quantity of bilious fluid this morning. Tongue dry;
mouth clammy; thirst; bowels open freely; urine free. The leg is free
from pain, and not swelled. Rep. haust. anodyn. h. s.
Dec. 27th. — Has had a very restless night. Continues to moan, and sigh, and
complain. The pain at the epigastrium is still severe, not much increased by
pressure ; there is a manifest fulness in that situation, with a tympanitic
state of the whole belly ; tongue dry and brown ; thirst ; has had no more
vomiting, but has’ nausea after taking any food ; bowels not open ; urine
free. Leg free from pain, and in good position.
Enema ; half-a-pint of ale.
Dec. 28th. — Has had some sleep. Bowels have been open three times to
night; less anxiety of countenance, and no moaning; the pain is much
abated; some tenderness in the right hypochondrium; belly tympanitic;
eructations ; very thirsty ; tongue dry and cracked down the centre, moist
at the edges; skin hot ; pulse 104, rather sharp, firm, and compressible.
Leg and arm lie well, without pain-
Haust. anodyn. h. s.
Dec. 29th.— Has slept well, and is now under the influence of opium, or is
CAUSES.
173
lapsing into a state of coma. Respiration hurried ; pulse exceedingly feeble ;
features shrunk. He lies low in bed ; he is free from all pain, hut is fast
sinking.
Died about four p. m.
Sec. Cad. — Twenty-eight hours after death. Head not examined.
Thorax. — Viscera healthy.
Abdomen. — About a pint of serum, mixed with flakes of lymph, in the
cavity. The peritoneum lining the small intestines, stomach, and con-
cave surface ot the liver, covered almost entirely by a slightly adherent
coat of colourless lymph, which in some parts (where it dipped down
between the folds of the bowels) was a quarter of an inch thick, and of the
consistence of the albumen in a hard-boiled egg. The peritoneal coat be-
neath it was everywhere remarkably bloodless, and no rupture of it was
detected.
The convex surface of the liver, as well as the substance of that viscus, was
perfectly sound.
The gall-bladder presented a very remarkable appearance. Its outer mem-
brane in three or four patches was in a state of slough. At these parts, the coats
of the gall-bladder were considerably thinner than elsewhere, (as was manifest
on holding the gall-bladder up to the light,) without, however, any breach of
either the outer or the inner coat, and were stained a bright yellow by the
bile. Those portions of the outer coat that were not sloughing, were of a
yellowish-white colour, (arising from opacity of the membrane, not from
lymph effused,) mottled by spots of purple and red from vascular injection.
The gall-bladder contained about an ounce and a half of thinnish bile, in
which floated several white flakes, like flakes of lymph. There was exten-
sive ulceration of the inner membrane, not corresponding in situation to the
sloughs noticed on the outside. The edges of the ulcers were slightly
raised, and their surface was coated with lymph, which might be readily
scraped off. In these parts the destruction of the reticular membrane was
complete s
Here, the first symptom referable to the gall-bladder, was
severe gnawing pain at the epigastrium and right hypochondrium,
which came on at noon on the 24th, two days after the accident.
The pain continued, increased by pressure, and the patient had like-
wise nausea, vomiting, and eructations. These symptoms cannot,
however, he ascribed entirely to the disease of the gall-bladder,
since there was extensive inflammation of the peritoneum, to which
they were probably in part owing.
The disease of the gall-bladder and the inflammation of tho
peritoneum were most probably caused by some injury done to
those parts at the time of the accident.
174
ULCERATION OF THE GALL-BLADDER.
Ulceration of the gall-bladder and ducts may lead to various
results.
1st. An ulcer, commencing in the mucous membrane of the
gall-bladder or of the common duct, may eat through its different
coats until the peritoneal coat is laid bare. The bile, brought in
contact with this coat, causes it to slough, and the contents of the
gall-bladder are poured suddenly into the cavity of the peritoneum.
When this happens, diffuse suppurative inflammation of the perito-
neum is set up, which destroys life in a few hours — quicker, per-
haps, in most cases, than the peritonitis that follows rupture of the
bowel.
If, however, the cystic duct have been long closed, and the gall-
bladder contain no bile, its contents may escape into the cavity of
the peritoneum by oozing. When the mucous coat is eaten
through, the matter may filter between it and the other coats, and
may escape by a rent of the peritoneal coat, at a point that does
not correspond to the ulcer of the mucous coat. The matter
escaping drop by drop causes inflammation of the serous mem-
brane, which is limited to the vicinity of the gall-bladder by adhe-
sions of coagulable lymph, so as to form a circumscribed abscess
in the cavity of the peritoneum. I have before cited from Cru-
veilhier an instance in which this happened. (See p. 16o.)
When the gall-bladder contains bile, this never occurs, because
when the bile reaches the peritoneum it causes it to slough, and the
contents of the bladder are discharged at once.
2nd. When an ulcer of the bladder or ducts is caused by a gall-
stone, adhesive inflammation of the serous membrane is usually
set up before perforation takes place ; the gall-bladder or duct be-
comes united to some adjacent part, generally the duodenum or
the colon ; the coats of the intestine are eaten through after those
of the gall-bladder or duct ; and the gall-stone passes into the in-
testinal canal.
Inflammation of the gall-bladder from gall-stones is less exten-
sive, is attended with less severe symptoms, and is less dangerous
in its results, than inflammation from other causes. The processes
of ulceration and adhesion are slow, and give rise to no violent
symptoms.
I have met with no instance of ulceration of the gall-bladder
ULCERATION OF TIIE COMMON DUCT.
175
extending in this way through the coats of the howel, except when
produced by a gall-stone.
3rd. Ulceration of the gall-bladder or ducts, like ulceration of
other mucous surfaces that return their blood to the portal vein,
may lead to scattered abscesses in the substance of the liver. In
the chapter on suppurative inflammation of the liver, several cases
are referred to in which abscesses in the substance of the liver
seemed to originate in ulceration of the gall-bladder or ducts.
The abscesses are probably the immediate consequence of suppu-
rative inflammation of a small vein in the vicinity of the ulcer,
or of the absorption of the ichorous matter of the ulcer.
In the large ducts, which lie close on the large branches of
the portal vein, an ulcer may eat into a branch of the vein, and
set up suppurative inflammation within it, hut the consequences
will, if possible, he worse than those of ordinary suppurative in-
flammation of the portal vein, because bile, as well as pus, will he
mixed with the portal blood. The dreadful effects of this are
fully exhibited in the following case, published by Dance, ( Archives
Generates, t. xix. p. 40, 1828), in which an ulcer in the common
duct ate into the portal vein.
A hairdresser, set. 25, of lymphatic temperament, was taken, without
known cause, in the beginning of October, 1828, until lassitude, loss of appe-
tite, thirst, and pain at the epigastrium. Some leeches applied there pro-
duced only slight relief. The 12th of October, he was brought to the Hotel
JDieu, with these symptoms, hut the pain at the epigastrium had increased,
and the tongue was then red and diy, yet the pulse was hut little quicker,
the skin little hotter, than natural. Twenty leeches were applied to the anus ;
— little amendment. The next day, fifteen leeches were applied to the epigas-
trium ; — considerable abatement of pain.
During five days, he continued to mend, the tongue became nearly natural.
Later, at two different times, the severe symptoms recurred, probably from
errors of diet. The first time, they were calmed by leeches to the epigas-
trium ; the second, they subsided without treatment.
At the end of October, the patient seemed convalescent, but he still suf-
fered at the epigastrium, and there was something in his condition altogether,
that we could not explain. At this time, pain in the right hypochondrium,
at first obscure, then more distinct, accompanied by bilious vomiting, and by
purging ; moderate fever, tongue natural. (Twenty leeches to the anus ;
hath.) Abatement of pain, continuance of vomiting and purging, the skin
gradually acquired the tint of decided jaundice.
The patient continued nearly in this state till the 12th of November. Then,
176
ULCERATION OF THE COMMON DUCT.
rigors recurring at irregular intervals, followed by frequency of pulse, heat,
and dryness of skin.
Two days later, acute deep-seated pain about the right shoulder came on
suddenly, swelling and tenderness of the soft parts about the joint, move-
ments of the arm very painful. (Poultices; V. S. “jviij.) The blood not
buffed.
Eight days had elapsed from the appearance of this new train of symptoms
when, all at once, the middle of the forehead became the seat of severe
pain, soon followed by swelling and tension, without change of colour in the
sk in. At the end of two days, the same phenomena at the left temple. The
swelling extends, by degrees, to the face and to the entire head, which acquires
an enormous size.
In the midst of these varied and serious disorders, the pulse is small, not
very frequent, compressible; the heat of skin moderate; the vomiting,
purging, and jaundice, continue ; the pains in the belly have ceased.
The swellings at the middle of the forehead and at the left temple go on
increasing; bullse filled with bloody serum appear here and there, and,
bursting, leave small spots where the skin seems mortified. These spots
extending, run together and form a single one, on the forehead and on the
temple, as large as a crown- piece, the surface of which is riddled with small
openings, from which small drops of pus can be pressed.
Some days before death, the tongue becomes red and dry, then black ;
the lips and teeth become covered with sordes ; the skin of the nose acquires
a brownish tint. Petechiae and small nodulous swellings appear on the skin,
and in the subcutaneous areolar tissue of the limbs and of the trunk ; the
patient falls into a 6tate of prostration and quiet delirium, and dies at three
p. m., on the 2nd of December.
Sectio Cadaveris eighteen hours after death.
Limbs not rigid. The surface of the skin sprinkled with petechial. By
the side of these petechial spots, are blackish, lenticular pustules, some con-
taining a sanious fluid, others a white homogeneous pus. These last ex-
tended into the subcutaneous areolar tissue, which was there infiltrated with
pus. This eruption was thicker on the legs than on the arms ; in front of the
trunk, than behind.
Head and face enormously swelled. Nose covered with a blackish crust,
involving the skin, which here appeared gangrenous. On the middle of the
forehead, on the left temple, and behind the left ear, soft, greyish, fetid
sloughs, under which the areolar tissue is infiltered with pus. The skin of
the forehead and of the anterior left half of the skull, was transformed
into a substance resembling bacon-rind, an inch thick, in the midst of
which could be distinguished many veins filled with pus. These veins
went to form the temporal veins, which, in the midst and on the surface
of the temporal muscle, in the zygomatic and pterygoid fossae, formed
an immense plexus, of which all the branches were filled with pus, and
bounded above by the black and softened fibres of the aforesaid mu»cle,
below by dense yellowish areolar tissue. The left parotid, quadrupled in
size, exhibited, when cut across, a granular surface, from which pus
EFFECTS.
177
flowed, by a thousand different points, in small round drops, that came solely
from the orifices of the numerous veins in the substance of the gland, many
of whose branches were traced, all filled with pus. These branches terminated
in the external jugular vein, which was inflamed as low as the middle of the
neck, and offered on the outside, an unnatural volume and hardness ; on the
inside, a reddish, roughened surface, covered with thick false membranes,
and, lower down, with clots of blood mixed with pus.
On the right side of the head, and under the scalp, abundant infiltration of
yellowish lymph, of the appearance of gelatine ; the temporal muscle pale
and soft ; the parotid and external jugular veins healthy; the anterior branch
of the temporal vein and all its divisions contain pus, collected into masses by
small whitish bands, interrupted here and there by small clots of blood. The
deltoid muscle on the right side, blackish, softened, traversed by a consi-
derable number of veins containing thick yellow pus. Muscles in other
parts of the body, brownish and easily torn. The right shoulder and elbow-
joints contained shreds of false membrane, and a small quantity of puriform
synovia. The other joints healthy.
Brain. Sinuses of the dura mater distended with black grumous blood,
without change of their coats. The cerebral substance pale and as if oede-
matous. The ventricles distended by colourless serum. The membranes
healthy.
Chest. Heart, of the usual size, colour, and consistence, containing a small
quantity of black fluid blood, presenting no trace of inflammation in its
cavities or in the coats of the vessels that terminate in it.
Pleura, not inflamed, and free from adhesions.
The lungs sprinkled with millions of small solid masses (‘engorgemens ’),
of various forms and sizes, more numerous in the right lung than in the left,
and in greatest number near the pleura, under which they formed promi-
nences visible to the eye. Some of these solid masses had a blackish tint,
others were whitish and granular, and broken down into a puriform
matter by slight pressure. None of them were converted into abscesses.
The pulmonary tissue around them was healthy, or slightly engorged with
bloody serum. It was ascertained by careful dissection, that these masses
were formed, in great part, of a mass of pulmonary veins, filled with pus
in their smallest ramifications. The veins of the lung contained pus in no
other points.
Abdomen.- The liver, of a dark brown colour, likewise containing many
purulent masses (c noyaux ’), most of them visible on the surface of the
organ, but without projecting above it. These masses appeared formed
of veins filled with pus, or at least to be the termination of them. We as-
certained their continuation with the radicles of the vena porta;. Many
branches of this vein, and its trunk, were full of a pulpy and puriform mat-
ter, of a yellowish colour, like that of bile, mixed with liquid blood and
with black or colourless clots, free or adherent. The inner membrane of
these vessels was covered by a thick layer of pus, and had below this a
rough and granular aspect : but in the greatest part of its extent, it retained
its natural polish, and was only whiter and more opaque than usual.
N
178
ULCERATION OF THE GALL-DUCTS.
Matter of the same kind was contained in the mesenteric veins which come
from the small intestine, in those which come from the pancreas, and in the
splenic vein. The coats of these vessels offered the same changes as those
of the former vessels.
All these veins, before reaching the trunk of the portal vein, traversed a
considerable mass, (d’engorgement,) formed, in front of the vertebral column
and in the whole length of the mesentery, by a collection of large red glands,
suppurating at the centre, and surrounded by dense areolar tissue infiltered
with pus.
The gall-bladder, filled with turbid serous bile, presented, towards its
base, four small round, blackish ulcers, extending through the mucous mem-
brane. The common duct was destroyed in its entire length, and converted
into an oblong winding cavity, containing membranous shreds detached from
its coats, and stained with bile. Behind, this canal offered several deep ulcers,
which extend through all its coats, and also through those of some large veins
adjacent. One of these ulcers opened into the superior mesenteric vein by
an orifice, a line in breadth, presenting a projecting and greenish edge in
the inner surface of the vein. The others might easily admit a moderate
sized probe.
The mucous membrane of the stomach, and of the intestines, everywhere
in its natural state, of good consistence, remarkably white, only coated by
thick, greyish mucus. About the entrance of the common gall-duct into
the duodenum, for the space of half -a-crown, the mucous membrane
was of a slate colour, softened, and presented four or five small deep ulcers.
The spleen was of a black-brown, and softened, but contained no pus.
Kidneys, firm, pale, healthy.
Bladder, healthy, filled with urine.
In tlie history of this case, the different stages of the disease are
marked out with tolerable distinctness. During the month of
October, it seems to have been confined to the mucous mem-
brane of the gall-bladder and ducts, and the symptoms were pain,
— which was twice relieved by leeches to the epigastrium, — lassi-
tude, loss of appetite, and thirst, without much fever. At the end
of October, during apparent convalescence, inflammation seems to
have been set up outside the common duct, by the ulcers eating
through it, and fresh symptoms occurred — return of pain in the
right hypochondrium, bilious vomiting, purging, increased fever,
jaundice. The 12tli of November, one of the ulcers had probably
eaten into a branch of the portal vein : rigors recurring at irregular
intervals, frequent pulse, and hot dry skin — the phenomena that
then set in — being constant symptoms in suppurative inflammation
of a large vein.
In the cases of suppurative inflammation of the trunk of the
EFFECTS.
179
portal vein, before related, the local mischief was confined to the
liver. The pus globules seemed all to be stopped there. In this case,
at the end of two days, the patient was seized suddenly with pain
and swelling about the right shoulder ; at the end of eight days,
with pain and swelling in the middle of the forehead ; at the end of
ten days, with pain and swelling of the left temple. Later still, pete-
chire appeared on the skin, and gangrenous pustules on the limbs
and trunk, and the patient died in a low typhoid state, on the 2nd
of December. After death, shreds of lymph and purulent synovia
were found in the right shoulder and elbow-joints, and small cir-
cumscribed masses in different stages towards suppuration, in the
lungs and liver.
The effects resembled those of suppurative phlebitis occurring
after injury of the head or limbs, but the inflammation set up in so
many distant points was more gangrenous than that consequent
on ordinary phlebitis. This may be readily explained, if we sup-
pose that the pus which contaminated the blood was in a state of
putrefaction. Its admixture with irritating bile, may, also, have
been concerned in the result.
The dissection rendered it clear, that the disease of the parts
remote from the liver resulted from contamination of the blood
with bile and pus, and that the morbid changes in those parts
began in inflammation of the minute veins.
The circumstance that there were no gall-stones, and that ulcers
were found in the duodenum immediately around the opening of
the common duct , as well as in the gall-bladder and in the duct—
scarcely leaves a doubt that the ulcers, from which all the subse-
quent mischief resulted, were caused by irritating bile. It is
worthy of remark, that there were no ulcers in the large intestine,
or anywhere in the intestinal canal, except immediately about the
opening of the common duct. It would seem, that the bile, mixed
with the food, and diluted, if we may so speak, with the pancreatic
juice, and the secretions of the bowel itself, became less irritating,
as it moved onwards.
The case confirms in a striking manner the opinion advanced
in a former chapter on the relation between abscess of the liver
and dysentery.
It shows, too, how serious may be the consequences of faulty
states of the bile, which in themselves may be transient, and of
which at present we know nothing.
N 2
180
CLOSURE OF THE CYSTIC DUCT.
Another occasional effect of the diseases we have been consider-
ing, is permanent closure of the cystic or of the common duct. This
may, indeed, arise from various causes besides inflammation. Per-
manent closure of the cystic duct is not unfrequently caused by a
gall-stone lodging in it. The gall-stone forms in the bladder, and
grows too large to pass through the duct. It is carried with the
bile, in which it floats, into the mouth of the duct, and gets firmly
lodged there. Circumscribed inflammation of the duct about the
gall-stone is then set up, by which the duct is in general permanently
closed beyond the gall-stone, towards the hepatic ducts. Some-
times, on the other side also, so that the stone is enclosed in a cyst.
Now and then, the common duct is closed in the same way, but
much less frequently, because the common duct is larger and
straighter than the cystic duct, so that when a gall-stone has passed
through the cystic duct, it in most cases passes also through the
common duct. But the common duct is also liable to be closed by
cancerous and other tumors, and especially by malignant disease
of the head of the pancreas. A few instances have been recorded,
in which it was permanently closed by some foreign body getting
into it from the duodenum.
The effects of mere closure of the ducts are just the same what-
ever he its cause, and it is as well, therefore, to speak of them once
for all.
Closure of the cystic duct destroys the office of the gall-bladder,
and leads to various changes in it, which depend chiefly on the
length of time the duct has been closed, and on the previous con-
dition of the gall-bladder.
When the cystic duct is closed by adhesive inflammation of
the capsule of the liver, and the coats of the gall-bladder were pre-
viously healthy, the bile in the gall bladder is absorbed, and its
place is soon occupied by a glairy fluid, of the consistence of
mucus or synovia, and not at all tinged, or but very slightly tinged,
with bile. After a time, this fluid is secreted in less abundance,
and the gall-bladder contracts and shrivels; in some cases, almost
to the size of an almond.
When the coats of the gall-bladder were previously diseased, and
secreting cholesterine, which is generally the case when the cystio
duct is closed by a gall-stone, the gall-bladder, after the closure of
the duct, will contain a viscid mucus sparkling with scales of clio-
CLOSURE OF THE COMMON DUCT.
181
lesterine, or be moulded on calculi almost entirely composed of that
substance.
It would seem from the cases before related, that closure of
the cystic duct impairs the nutrition of the gall-bladder, and in this
way, as also by the long retention of bile, when this is unhealthy,
renders it much more liable than in its natural state, to inflamma-
tion and sloughing.
The effects of closure of the cystic duct on digestion and the
general health, are much less serious than might have been ex-
pected, and sometimes are of very little import. I have lately
met with a striking instance of this in a man, 64 years of age,
who died in King’s College Hospital, of extensive softening
of the brain, and of inflammation of the urinary bladder which
was consequent on the cerebral disorder. I did not expect
to find anything amiss in the liver. The man’s complexion
was remarkably clear, and in the notes of his case, which were
taken with much care, there was no mention of any disorder of
digestion. The gall-bladder was filled by a mass of small stones,
which choked the mouth of the duct, and completely prevented the
entrance of bile. (See plate 2, fig 3.) From subsequent inquiry
of his friends, I learnt that he had never had jaundice, and never
complained of disordered digestion.
My friend, Dr. Scott Alison, has lately sent me a gall-bladder,
in which the orifice of the cystic duct was closed, and apparently
had been closed long before death, by a gall-stone, the size of a
hazel-nut. The bladder was filled by viscid mucus, sparkling
with scales of cholesterine, and its coats were diseased. It was
taken from a lady who died, at the age of 79, of acute bronchitis, of
eight days date, and who, before this illness, had been particularly
healthy. She was of very temperate habits, and bad never had
jaundice or other symptoms to lead to the inference that the liver
was diseased.
It has been stated, that closure of the cystic duct, by causing the
bile to flow continuously into the duodenum, increases the appetite
in a remarkable degree (Diet, de Med. t. v. p. 24 1 ) — but tliis effect
was not noticed in the cases just mentioned, and in many others to
which I could refer.
Closure of the common duct has far more serious effects.
The most immediate of these, arc deep jaundice, dilatation of the
182
CLOSURE OF THE COMMON DUCT.
gall-bladder and hepatic ducts, and retention of bile in the lobular
substance of the liver, which acquires in consequence a deep olive
colour. By the retention of bile, tlie liver at first grows larger,
but its increase of size from this cause is, perhaps, never very great.
Subsequently, from atrophy of the lobular substance, it shrinks
again, and in the end, notwithstanding the dilatation of the gall
ducts, becomes much smaller than in health.
If the closure of the common duct occur suddenly, the gall-
bladder, or one of the ducts behind the obstruction, may be dis-
tended so rapidly as to burst. Several cases of this kind are re-
corded. (See case cited from Andral, p. 155.)
When the obstruction occurs gradually, the bladder and ducts are
distended more slowly, and when the duct has been long com-
pletely closed, ore sometimes found of enormous size. Aber-
crombie (Diseases of Stomach, &c., 2nd edition, p. 364) cites
from Boisment, a case in which the hepatic gall-ducts were so
distended in this way, and the lobular substance of the liver was so
wasted, that the liver had the appearance of a large undulating
cyst. The closure of the common duct was caused by a mem-
branous band which passed over it.
The ultimate effect of closure of the common duct on the lobular
substance of the liver, is very remarkable. The cells which go to
form this substance, and which secrete the bile, are destroyed ; the
capillary vessels of the lobules, which minister to secretion, their
office gone, waste ; the liver shrinks, and no longer presents an
appearance of lobules ; and its office is no longer in any degree
performed.
The destruction of the proper cells of the liver was first noticed
by Dr. Thomas Williams, in a paper “ on the Pathology of
Cells,” published in Guy's Hospital Keports, for October, 1843.
Dr. Williams remarked it in a man who died in Guy’s Hospital
of malignant disease of the duodenal end of the pancreas, which so
pressed upon the common duct, that the bile could have passed into
the duodenum only in very small quantity, and very slowly. The
gall-bladder and ducts were extremely distended, and the whole
organ was considerably enlarged. “ The fiver had lost its fragile,
solid character, and had become soft, flabby, and not capable of
being easily broken down by pressure. On the application of the
microscope for the purpose of examining the ultimate structure,
the extraordinary fact was developed, that scarcely a single nu-
6
EFFECTS.
183
cleated glandular cell, in a perfect state, could be found. Different
portions of the organ were carefully and repeatedly prepared, in
order to remove every possibility of mistake or misobservation ;
the conclusions were uniformly tlie same, that the true parenchymal
cells of the organ were certainly not present. These preparations
were also seen and examined by several excellent observers about
tlie hospital. In each portion of the organ mounted for inspection,
nothing more than miuute free fatty particles, and equally free,
floating, amorphous, granular matter,
could be discovered : it was very sel-
dom that a whole nucleated cell could be
seen. The following cut may serve to
convey a conception of the microscopic a> ^at Part^es’ ^ree-
characters of these objects.”
In the spring of the present year, (1844,) I met with a case, in
which from long closure of the common duct, the cells of the liver
were perhaps even more completely destroyed than in the case
related by Dr. Williams. I shall give the case in detail, because
from there being no disease elsewhere to render the result am-
biguous, it shows, clearer than any of the experiments made on
animals, the effect of closure of the common duct.
Case. — Ann Diprose, set. 63, a sempstress, was admitted into King’s Col-
lege Hospital, on the 18th of May, 1843. She was born in London, and had
passed her life in it ; of temperate habits, never taking spirits ; married ; has
had six children, and five miscarriages ; the catamenia appeared at the age
of 17, were regular, except when interrupted by pregnancy and suckling, and
ceased at the age of 38.
Enjoyed good health till about fifteen years ago, when, after a fire which
destroyed much of her husband’s property, she was seized with violent pains,
extending from the feet to the thighs. They were relieved by cupping at the
back of the neck. A year after this, the muscles on the right side of the face
were spasmodically contracted for six weeks. For this, she had first strength-
ening, and then depleting remedies. About eleven years ago, she fell down
suddenly in the street, with loss of sensation and motion, from which she
perfectly recovered in six weeks, during which she was blistered at the back
of the head. She had no further illness till five years ago, when she suffered
from pain and swelling in the right iliac region, attended with constipation.
The pain gradually became very severe. It yielded to leeches, blisters, and
low diet, after continuing from three weeks to a month. She perfectly re-
covered from thi3 attack, and her health was good till her present illness,
which began seven months ago, after great fatigue and anxiety, in attending
her mother who was then, in her 91st year, operated on successfully for stran-
gulated hernia.
184
CLOSURE OF THE COMMON DUCT.
At this time, her face and body became gradually of a deep yellow colour,
which, with some diminution for one interval of three weeks, has continued
ever since. The jaundice came on without pain, but with some degree of
nausea ; and was followed, at the end of two months, by vomiting, which has
recurred at intervals up to the present time.
The appetite, at times, quite gone ; at other times, ravenous. Has always
found herself worse, and the jaundice deeper, after anxiety or fatigue.
Four months ago was salivated, without relief. Has wasted much since
her illness.
On her admission to the hospital, the conjunctive and the whole sur-
face of the body were of a greenish colour. She was thin, but not emaci-
ated- There was much itching of the skin ; surface cold ; frequent shivers.
Pulse, S8: regular. Respiration, 22. Nothing discovered amiss in the heart
or lungs by auscultation and percussion.
The tongue was clean ; the appetite very variable, and sometimes vora-
cious ; occasional nausea, but no vomiting for the last week ; bowels confined ;
evacuations clay- coloured and fetid. Great tenderness over the whole belly,
but no pain. There was dulness on percussion over the epigastrium, and
for some distance below the right false ribs, which was ascribed to en-
largement of the liver. No ascites. The abdominal muscles irritable.
The urine was of dark colour; S. G. 1015 ; nitric acid produced at first
a deep green, and when added in excess, a purple colour.
Some headache and depression of spirits. Sleep good, but easily disturbed.
She was ordered inxx. of dilute nitric acid, three times a day ; and compound
colocynth pills, when necessary, to keep the bowels open.
She remained in the hospital till the 8th of June, and during this time the
symptoms underwent no material change. There was no fever ; the skin
was cool ; the tongue, moist, pallid, and indented ; and she was seldom
thirsty; the pulse ranged from 86 to 90; the S. G. of the urine from 1015 —
1020. She complained often of tenderness at the epigastrium, and at times of a
gnawing pain there, which was relieved by taking food. Had frequent
nausea, especially when the stomach was empty, but only vomited once — and
then in the morning, in consequence, as she thought, of having taken
the night before a draught containing the fourth of a grain of muriate of
morphia.
A few days after she left the hospital, she was much troubled by her hus-
band returning to her, ill — and from that time she became much weaker, and
did not afterwards leave her bed, except for a short time in the evenings. She
continued to take the nitric acid, which she thought did her good. There was
great tenderness over the epigastrium and right hypochondrium, with rigidity
of the abdominal muscles j she was unable to he on the right side, and generally
preferred the supine posture. She was very nervous, — the least noise, or even
sewing or reading, producing a “ fluttering of the chest ;” — and her sleep was
more disturbed than it had been previously. She often became hot and
feverish about night-fall, and continued so during the night. Complained at
times of pain in the ankles and wrists, but these joints were not red or
EFFECTS.
185
swollen. She had no vomiting. Her appetite was at times voracious ; and
she had a craving for oysters and small shell fish, which, even in large quan-
tities, never disagreed with her. She had an aversion to meat, and porter,
and milk, — which she said disordered her.
One evening, after imprudently eating gooseberry tart, she was seized with
violent pain and spasm under the right false ribs, which exhausted her very
much, but did not cause vomiting.
On the 27th of June, the nitric acid was exchanged for sulphate of quinine
and dilute sulphuric acid ; and this, again, was soon exchanged for nitro-mu-
riatic acid, which she continued to take with short interruptions till the end
of December.
During this time, she grew weaker and thinner, and was harassed by occa-
sional hectic at night. In other respects, her symptoms underwent little change.
Her appetite was almost constantly craving, and she still had great desire
for mussels and oysters. There was no vomiting. Her bowels habitually
required purgative medicines, but, in the middle of December, she had diar-
rhoea. which lasted for a week, during which she felt better. She always
complained of pain and tenderness of the belly, and often of itching of the
skin. Slept badly by night, and was drowsy by day. The pulse ranged
from 88 to 100; the respiration from 20 — 24. She had frequent cough, but
did not expectorate. The urine was ever high-coloured, fetid, stained linen
yellow, and on the addition of nitric acid became first of a beautiful green,
and then of a purple colour. It was sometimes clear, at other times turbid,
but never deposited a sediment approaching to pink.
A little before Christmas she suffered much from thirst, and effervescent
draughts were given to allay it. She relished them very much, and continued
to take them till her death, which happened on the 10th of March.
In the beginning of February, she lost one of her sons, who died rather
suddenly, from disease of the heart. From this time, her appetite began to
fail, and the last few weeks of her life she ate very little. She complained of
nausea, and now and then vomited. Often had shivers, followed by burning
heat of skin. Complained greatly of pain and soreness of the belly; and at
times of pain of the head, of a throbbing character. About a week before
her death, vomiting of blood came on, and recurred two or three times.
The last week, her mind wandered a little at night ; but, with this excep-
tion, she continued rational up to her death, which seemed to result from
exhaustion.
The urine was examined for the last time on the 21st of February. It had
the same characters as previously, and its S. G. was 1012.
Two or three times morphia and conium were given to procure sleep, hut
these medicines disordered her, and increased her sufferings.
The body was examined twenty-two hours after death.
It was much emaciated, and of a greenish-yellow colour.
The belly was large. The cavity of the peritoneum contained three or
four pints of a serous fluid, and the intestines were much distended
with gas.
186
CLOSURE OF THE COMMON DUCT.
The colon was closely united to the gall-bladder by false membranes of old
date. Its mucous membrane, even at this point, was not at all altered in
structure, and its canal was not contracted.
The duodenum also adhered firmly to the gall-bladder for a very small
space, about an inch and half below the pylorus. The canal of the intestine
was a little curved by this adhesion, but not sensibly contracted. The mu-
cous membrane of the duodenum was quite healthy.
There were a few threads of false membrane uniting contiguous loops of
intestine.
The mucous membrane of the stomach and intestines presented no sensible
change of structure. The duodenum contained a whitish pulpy matter; the
large intestine firm white foecal matter, and much gas.
The liver was smaller than natural, and looked flattened. It was of a deep
olive, finely mottled with yellow. Its surface presented no traces of peri-
tonitis, except about the gall-bladder, and was readily thrown into fine
wrinkles. The hepatic gall-ducts were enormously dilated, every section of
the liver presenting some of the size of goose-quills. The tissue of the liver
was flabby, but not easily broken down by the finger. The cut surface was
of a deep olive, finely sprinkled with yellow — having somewhat the appear-
ance of fine grained granite — but the lobules could not be distinguished in it.
When some of the tissue from any part of the liver was examined under the
microscope, nothing was seen but numerous oil globules, and irregular par-
ticles of yellow and orange biliary matter, which was in many places agglome-
rated into roundish masses. No distinct cells were visible. The matter taken
from the yellow points appeared to differ from the matter of the olive portions
only in containing more oil globules, and less biliary matter.
The tissue of the liver was in the same state throughout.
The gall-bladder and cystic duct were enlarged, the latter to the size of the
little finger. Their coats were much thickened. The outer coat had a dead-
white colour, and was of the firmness of cartilage, but presented no calcare-
ous plates. Both were stuffed with small irregular tetrahedral calculi, the
interstices of which were filled by a fight yellow fluid, of the consistence of
thin cream, which under the microscope presented nothing but a mass of
very minute crystals of cholesterine, (some of which were stained yellow,) with
here and there a particle of biliary matter.
The thickened coats of the gall-bladder and cystic duct, exhibited under
the microscope oil globules and plates of cholesterine.
The common duct was completely closed just below the point where the
cystic duct enters it. Between this point and its opening into the duodenum, it
was very narrow, just admitting a small probe. Its coats not at all thickened
or diseased, and not stained with bile. Immediately above the entrance of the
cystic duct, the hepatic ducts were dilated to the size of a man’s thumb. Their
coats were stained of a deep olive, but were not thickened. Some of the
dilated ducts contained a little dark green fluid.
The gall-bladder was not quite closed to the hepatic ducts. Some of the
contents of those ducts might soak into the gall-bladder through the im-
pacted mass of calculi.
EFFECTS.
187
The hepatic artery appeared to be of its natural size. The portal vein was
healthy, and did not seem compressed by the gall-bladder and cystic duct.
In the loose areolar tissue near the entrance of the portal canal, were some
lymphatic glands of a dark olive colour.
The thoracic duct was small ; in the posterior mediastinum not larger than
the quill of a hen.
The spleen had thick white spots of false membrane on its capsule— but was
firm, and not enlarged.
The kidneys were healthy.
The heart healthy. Its ventricles, which were contracted, contained only
very small fragments of fibrine.
The lungs were sound, but were united to the pleura costalis on each side
by a few threadlike bands. There were no false membranes uniting the lower
lobe of the right lung to the diaphragm.
There was some serous fluid in each pleural cavity.
In the case just related, closure of the common duct was
evidently the chief, if not the sole cause of the woman’s suffer-
ings during more than the last year of her life. The gall-
bladder and cystic duct were, indeed, stuffed with small gall-stones,
hut there were no marks of recent inflammation about them, and
there was no disease elsewhere, by which the symptoms could
have been produced. It is difficult to fix the precise time when
the duct became completely closed. From the circumstance, that
the jaundice came on gradually, and without pain, the inference
can scarcely be avoided, that the occlusion took place very
gradually, for the sudden closure of the common duct by a gall-
stone, or otherwise, usually, if not always, gives rise to a train of
very urgent symptoms — pain, vomiting, faintness. It is not im-
probable, that in this case the first occurrence of vomiting, about
two months after the onset of the disease, and about fifteen months
before death, marked the completion of the process.
Among the many points of interest the case presents, we may
notice first, the effect which this long closure of the common duct
had on the liver itself. Great dilatation of the gall-ducts, and a
dark green colour of the liver are results which might have been
predicted — hut results far more curious and interesting are, the
shrinking and flattening of the liver, the absence of distinct lobules
in its substance, and the complete disappearance of the nucleated
cells by which the bilo is secreted. The liver was made up of vessels
and areolar tissue connecting them, with the free oil-globules and
188
CLOSURE OF THE COMMON DUCT.
solid particles of yellow and orange biliary matter, that were left
when the watery and more soluble parts of the retained bile were
absorbed. The objects seen when some of the tissue from any part
of the liverwas examined under the microscope, were just the same
as in the case related hy Dr. Williams, and confirm in almost every
respect Dr. Williams’s account. Perhaps no instance could be
brought forward from the infinite variety of disease, that shows
more strikingly the necessity of employing the microscope, if we
wish to gain clear insight into morbid anatomy.
Destruction of the proper cells of the liver, seems to occasion
atrophy of the capillary vessels subservient to their secretion —
and the two circumstances, combined, explain the shrinking
of the liver, and the absence of any appearance of lobules. The
cessation of the process of secretion, and the wasting of the
capillary vessels, probably renders the passage of the blood
through the liver less free, and thus accounts in some measure
for the vomiting of blood which occurred the week before
death, and for the serous fluid which was found after death
in the cavity of the peritoneum. Bouisson, in his recent work on
the bile, (De la Bile, &c. p. 138,) gives a short account of a
case in which death resulted from closure of the common duct, and
which resembles in many particulars the case of Mrs. Diprose.
The patient, a man, 64 years of age, seems to have had good
health till the illness which ended in bis death, and which came on
slowly, and without urgent symptoms, after stroug mental emotion.
He gradually became jaundiced, and gradually lost flesh. The
jaundice became very deep, and lasted till his death. The lower
end of the common duct was obliterated. Its upper end, the gall-
bladder, and the hepatic ducts were much dilated. In the dilated
end of the common duct, there was a tumor, seemingly fatty,
which adhered to its lining membrane at several points. No
mention is made of vomiting of blood, but towards the close of
life the stools were often bloody. The intestinal canal was healthy,
and exhibited no trace of inflammation.
Other points worthy of notice, in the case of Mrs. Diprose,
and which were among the effects of closure of the common duct,
are : —
1st. — The constipation, and the relief she derived from purga-
tives, and once from diarrhoea, that occurred without purgative
EFFECTS.
189
medicine. Much of the pain and tenderness of the belly of which
she complained, was probably owing to distension of the intes-
tine by fleeces and gas, and to irritation of its mucous membrane
by the contact of matters chemically different from those natural
to it.
2nd. — The ravenous appetite she so long had, which probably
depended, as in diabetes, on imperfect digestion. I have known
the same thing happen where the common duct was closed by the
pressure of a cancerous tumor.
3rd. — The desire she had for shell-fish — especially oysters and
mussels, which, in quantity to satisfy a craving appetite, never
disagreed with her.
4th. — The fetid urine, — which was at times turbid with pale
lithates, but never had a pinkish sediment. The absence of a
pink sediment may help to distinguish such cases from cases in
which the common duct is closed by the pressure of a cancerous
tumor, and in which a sediment of this tint is often observed in
the urine.
5th. — But, perhaps, the most striking circumstance of all was,
that although for a long time before death the liver must have
ceased to separate bile from the blood, there were no symptoms of
cerebral poisoning, and the mind remained clear to the last. This
circumstance will appear still more remarkable, if we compare this
case with other cases in which suppression of bile is attended with
delirium, or with stupor and convulsions, soon ending in fatal
coma. Dr. Alison, in a paper published in the Edinburgh Me-
dical and Surgical Journal for 1835, has collected many cases of
this latter kind, and from a review of them he concludes, that it is
jaundice from suppressed secretion , and not from obstructed gall-
ducts, that is peculiarly, if not exclusively, liable to be followed by
delirium, coma, and speedy death. He explains this, hy supposing
that “ the retention in the blood of matter destined to excretion, is
much more generally hurtful to the living body than the re-
absorption into the blood of matters which have been excreted at
their appropriate organs, but not thrown out of the body, in con-
sequence of obstruction at their outlets.” The fact is, I believe,
correct, but Dr. Alison's explanation is not satisfactory, since, in
this case, for a long time before death there could have been no
bile secreted, and yet there was no disorder of the brain.
The case further shows us, that the secretion of bile by the liver
190
FATTY DEGENERATION
is not immediately necessary to life — that a person may live a con-
siderable time when the liver, as an instrument of secretion, is
completely destroyed. This destruction of the secreting element
of the liver proves fatal, however, in the end, by impairingnutrition
and causing gradual hut progressive wasting. The time requisite to
wear out life, must depend on the age and previous strength of the
patient, his powers of digestion and assimilation, the nature and
quantity of the food taken, and the various other circumstances that
influence nutrition. It will, of course, be shortened by the inju-
dicious employment of lowering measures. In Mrs. Diprose, the
cells of the liver had probably disappeared, and the organ had
ceased altogether to secrete bile, many months before death.
Other cases have occurred, in which, judging from the duration
of complete jaundice, or the state of the liver after death, life must
have continued much longer after this had happened.
Some months ago, my attention was called by Mr. Busk to a
patient in the Dreadnought, who had then been jaundiced for four
years, and, as I imagined, from closure of the common duct. During
this time no bile seems to have passed into the bowel. The
, faeces were always pale ; and the year before I saw him, he
had taken strong emetics, which produced free vomiting, hut, as
he stated, nothing bilious was brought up. He was still tolerably
stout and muscular. In the case related by Boisment, already
alluded to, where, from extreme dilatation of the gall- ducts and
wasting of the lobular substance, the liver had the appearance of
a large cyst, the cells must have disappeared, and the liver, as a
secreting organ, must have been completely destroyed, long previous
to death.
These cases might lead us to expect, (what indeed happens,)
that persons who, from obliteration of branches of the portal
vein, or the other changes so frequently produced by long resid-
ence in tropical or malarious climates, have very little liver left, —
to use a common expression, hut which, if we consider the liver
as a mere agent of secretion, is strictly correct, — might often, by
careful management, enjoy tolerable comfort for many years.
Another circumstance worthy of notice in the case of Mrs. Diprose,
is the state of the coats of the gall-bladder, which were thickened and
opaque, and when examined under the microscope, exhibited nu-
merous oil globules and transparent scales of cholesterine. This dis-
OF THE GALL-BLADDER.
191
ease of the gall-bladder is analogous to the ‘ atheromatous’ disease
of arteries, -which Mr. Gulliver has lately designated, “ fatty dege-
neration of arteries,” from having discovered that the atheroma-
tous matter is chiefly composed of fat, in the form of oil-glo-
bules and scales of cliolesterine. This disease of the gall-bladder
may, therefore, be termed with equal propriety, fatty degeneration
of the gall-bladder ; an expression, which has the merit of involv-
ing no theory as to the cause of the disease, hut merely announc-
ing a fact. In the gall-bladder, as in the arteries, phosphate of
lime is often deposited with the fatty matter, and sometimes in
such quantity as to form large bony plates, which on the inside of
the gall-bladder are usually bare, or merely covered by a soft pulpy
matter, which may be readily scraped away. Sometimes, the earthy
matter is in such quantity that the gall-bladder is almost con-
verted into a bony cyst.
This disease of the gall-bladder may perhaps be an occasional
consequence of inflammation, hut it probably results more fre-
quently from other causes, constitutional and local, which affect
the nutrition of its tissues. It sometimes involves the entire
gall-bladder ; in other cases, merely a part of it. In a gall-
bladder sent me by Dr. Alison, (of which I have already spoken,)
which was taken from a lady who died at the age of 79, much
of the under and free surface was rigid from calcareous plates,
which on the inside were covered only by a soft pulpy mass, com-
posed of fatty matters and mucus. About the neck of the gall-
bladder, and on the side of it attached to the liver, the coats
were not at all thickened, and seemed healthy. The diseased part
was limited by a well-defined line, readily seen on the inside of the
bladder. The mouth of the cystic duct was blocked up by a
calculus, composed almost entirely of cliolesterine, and the bladder
was filled by a viscid matter of a dirty yellowish- green colour, and
sparkling with small scales of cliolesterine.
This disease of the gall-bladder is very important, from its
being always attended by a large secretion of cliolesterine in the
gall-bladder, which frequently leads to the formation of gall-
stones and all the evils they occasion. It is perhaps confined to
persons advanced in life ; and, according to my own observation,
it is much more common in women than in men. Sedentary
habits and modes of life conducive to fat, probably favour this
degeneration.
192 INFLAMMATION OF THE GALL-BLADDER AND DUCTS.
The cases that have been related in this chapter exhibit, pro-
bably, the chief forms of inflammation of the gall-bladder and
ducts. We may gather from them, that when catarrhal or suppu-
rative inflammation is confined to the gall-bladder, or to the gall-
bladder and cystic duct, the chief symptoms are pain and tender-
ness in the site of the gall-bladder, vomiting or nausea, and a
certain degree of fever. When from the first the inflammation is
not severe, or when its first flush has passed by, these symptoms
may be very slight, and excite little attention, or be even entirely
disregarded. When, again, inflammation of the gall-bladder occurs
during typhoid fever, or in the midst of other severe constitutional
disorder in which sensation is blunted, pain will be little com-
plained of, and the other symptoms lose almost all their signifi-
cance. Ulceration of the gall-bladder, when it involves only a
small part of the organ, may exist without fever or other consti-
tutional disturbance, and with only occasional pain, and may be
almost unheeded, till by sloughing of the peritoneal coat, the con-
tents of the bladder are poured into the cavity of the peritoneum.
The symptoms that precede this accident are not such as to impress
us with a notion of danger, and we require fuller knowledge than
we now have of the circumstances in which ulceration of the gall-
bladder occurs, to make us alive to their true meaning. When in-
flammation involves the hepatic ducts or still more the common
duct, and, by causing thickening of their mucous membrane or
secretion of viscid mucus, prevents the passage of bile, in addi-
tion to the symptoms mentioned above — more or less pain and
tenderness, winch we may expect to he more diffused than when
the gall bladder alone is diseased ; vomiting, perhaps, or nausea ;
and more or less fever, — there will be jaundice. The jaundice,
attended by slight pain in the region of the liver, and by slight
fever, that occurs in young and previously healthy persons, de-
pends, perhaps generally, on an inflamed state of the gall-ducts,
which, from their small size, must he readily closed by swelling of
their mucous membrane or a viscid secretion from it.
When inflammation involves the common duct only, and is of
such nature as to close it, the symptoms are very peculiar —
pain confined to a small spot in the situation of the common
duct, early jaundice, and early distension of the gall-bladder, so.
as to form a large moveable, pear-shaped tumor, not painful or
tender.
TREATMENT.
193
The immediate cause of most of the forms of inflammation of the
gall-bladder and ducts under consideration, is, -without doubt, the
passage of irritating bile, or the mechanical irritation of gall-stones.
Perhaps it may be stated more generally, that inflammation of the
ducts of glands, and especially inflammation terminating in the clo-
sure of these ducts, is almost always caused by the passage of irri-
tating excretions. As regards the ureter, this is notoriously the
case. The circumstance, that the bile becomes more concentrated
in the gall-bladder, and, if faulty, more irritating, sufficiently ac-
counts for the various forms of inflammation being so much more
frequent in the gall-bladder and in the cystic and common ducts,
than in the hepatic duct and its branches. Long intervals be-
tween meals, by contributing to this, probably disposes much to
those diseases of the gall-bladder.
In the treatment of inflammation of the gall-bladder and ducts,
a most important principle is the early employment of local depletion.
Leeches, as was seen distinctly enough* in some of the cases that
have been related, l'elievethe pain and tenderness, and no doubt miti-
gate the inflammation, and, in consequence, lessen the danger of per-
foration and of permanent closure of the ducts. The value of this
practice has been more or less vaguely recognised in jaundice, but
its importance in the class of cases we have been considering,
has not perhaps been enforced by a perception of tbe powerful
motives which their peculiar dangers furnish. It should always
be borne in mind, that, here, a disease attended with but little
pain and fever, and, at first, with no alarming symptoms, and,
indeed, trivial in itself, may, from its situation, prove mortal.
The precept to be drawn from this truth, may be made general.
In all cases where canals form an essential part of vital organs,
mechanical considerations come to be paramount, and give an
importance to diseases which in themselves are trivial. In
stricture of the pylorus, from thickening and induration of the
submucous areolar tissue, and in the endocarditis of acute rheu-
matism, this truth is strikingly exemplified. In such cases, our end
must be, not so much to relieve the present symptoms, which are
often slight, as to prevent those changes of structure, which, slowly
it may be, but inevitably, and with much suffering, destroy life.
How infinitely valuable, then, is that insight which enables us to see
the danger before it is revealed to other eyes, and when alone we
o
194 INFLAMMATION OF THE GALL-BLADDER AND DUCTS.
can effectually guard against it ! This insight we can derive
only from knowledge of the circumstances under which these forms
of disease occur ; knowledge, which gives meaning to symptoms,
otherwise vague, and perhaps so slight as to he scarcely regarded.
Blisters have the same land of efficacy as leeches. Like
these, they often relieve the pain and tenderness in a striking
manner, and therefore, we may infer, tend also to prevent per-
manent changes of structure. The proper time for blister-
ing is when the pain and fever have abated under leeches and
other measures, and it is no longer deemed advisable to take away
blood.
Another important principle in the treatment of these cases, is
the strict enforcement of a plain and appropriate diet. As a par-
ticular point in the diet to he observed, the free use of diluents
may have some advantages. While, by filling the stomach, they
help to empty the gall-bladder by their pressure, it is also pro-
bable that, after absorption, they pass out of the circulation again,
in part by the liver, and thus dilute the bile.
In certain cases of the class now under consideration, the ju-
dicious use of mercury is attended with signal good effects. It
probably acts beneficially in two ways : — 1st, by increasing the
quantity and by promoting the flow of bile ; and, 2nd, by produc-
ing changes in its quality which render it less-irritating. These
are the objects that determine the principles of its administration
in these cases, in which the desired effect is best obtained, not by
the more powerful and constitutional action of the drug, — which
should be studiously avoided, — but by the occasional administra-
tion of its milder preparations, repeated as need may be. It is to
the striking benefit sometimes derived from mercury used in this
way, that this medicine owes the reputation it has long had as
a remedy in liver diseases.
Soda is another medicine much in use in the treatment of these
cases, and there is reason to believe that it deserves the esteem in
which it is generally held. Physiological considerations would
lead us to suppose that it is best suited to cases of catarrhal in-
flammation of the ducts. As soda is a natural constituent of bile,
and is therefore, — we may infer, — readily excreted by the liver,
it probably renders the secretion from the ducts less viscid, and
has the same sort of efficacy in these cases as in catarrhal diseases
of the lungs, in which this and other alkalies have been long
used as expectorants.
TREATMENT.
195
As most of the various forms of disease of the biliary passages,
considered in this chapter, may be traced to a faulty condition
of the bile, so it may be stated, as a general principle, that, as far
as medicines are concerned, the best remedies are to be found
among those agents which modify the qualities of that fluid.
Among these, taraxacum holds an important rank. Its powers are
very variously estimated by practitioners, but I have already given
reason to believe that its efficacy, like that of cholagogue medicines,
generally, is more likely to be under than over-rated. That it
should continue to be held in such high esteem by so many accu-
rate observers, is a strong testimony in its favour, and as it has the
further advantage of being perfectly safe and harmless, there is
every reason for giving it an extensive trial in the treatment of
these cases.
When the process of inflammation is over, and the organic
changes produced by it only remain, the inefficacy of all active
treatment is obvious. When, for example, — to take an extreme
case, — the common duct is obliterated, mercury and other
lowering measures must do positive mischief, and the rule of
treatment becomes that of avoiding all active interference. In
such a case as this, there is little more to be done, than to
regulate the diet and to prevent accumulation of noxious matters
in the bowels by an occasional warm purgative. The great ques-
tion is, how is the fact of occlusion to be made out? When
complete jaundice has lasted a long time, this, of itself, is almost
proof of permanent closure of the duct in some way or other, and
should deter us from the use of mercury and all lowering remedies ;
but in the absence of this evidence, the point must remain doubt-
ful. In that case, we must give the patient the chance afforded by
more active treatment, and, in the endeavour to do good, must
run the risk of doing harm. This is but one of the countless
questions which continually call up the remark, that, in diseases
of the liver, beyond all others, diagnosis is the very foundation of
treatment, and that to render our diagnosis more sure, should,
for the present, be the chief object of our researches. This end will
be best attained by more perfect knowledge of the physiology and
uses of the bile, on the one hand, and by a more accurate study
of the circumstances under which the various diseases of the liver
arise, on the other.
19G
CHAPTER III.
DISEASES WHICH RESULT FROM FAULTY NUTRITION OF THE
LIVER, OR FAULTY SECRETION.
Sect. I. — Softening of the liver — Destruction of the hepatic
cells — Suppressed secretion of bile — Fatal jaundice.
Having considered the inflammatory diseases of the liver, we may
pass on to a class of diseases, at present less understood ; diseases
in which, seemingly without inflammation, the secreting power, or
the nutrition of the hepatic cells and other tissues of the liver, is
seriously disordered. These diseases may he divided into two
principal groups. One of these groups is characterised by sus-
pension of the secretion of bile ; the principal feature of the other
is, that the hepatic cells separate from the blood some abnormal
matter, which, instead of passing freely out of the liver in the bile,
is retained there, adding to the size of the liver, and more or less
changing its appearance and texture.
To understand how changes in the appearance and texture of
the liver are produced in this way, we must again refer, for a
moment, to the intimate structure^ of the organ.
We have seen that the lobules of the liver are spaces mapped
out by the ultimate twigs of the portal vein, which are hairy, as
it were, with capillaries springing immediately from them on
every side, and forming a close and continuous network ; and that
the interstices of these capillaries are filled with nucleated cells.
It is in these cells that the vital chemistry of secretion goes on.
It is seen by the microscope that in different livers, the cells vary in
size ; that in some they are almost transparent, in others opaque,
and apparently more solid ; that in some they contain hut a few very
small oil- globules, while in others, they are distended almost to
bursting with globules of oil ; that in some, they are colourless or
4
FATAL JAUNDICE.
197
nearly so, and in others, yellow with bile ; that in some specimens,
again, as in the case of Mrs. Diprose, before related, they are broken
down and destroyed. It is probable, too, that in some cases the cells
are only slowly reproduced ; that, without complete destruction,
they become less productive of new cells, so that at length the
number of active cells is much diminished.
These differences in the condition of the cells cause, of course,
corresponding differences in the size, colour, and texture of the
liver ; differences, which were noticed long before that knowledge
of the intimate structure of the organ was obtained, by which we
are now enabled to explain them.
The most remarkable and most serious change is, where the
cells are completely broken down and destroyed. It has been
seen that this may result from long retention of the secreted bile
from closure of the common duct. In consequence of this, the
hepatic gall-ducts become enormously dilated, and the whole
liver acquires a deep olive colour. Its tissue is flabby, hut not
readily broken down by the finger, and presents no appearance of
lobules. Every part of the liver is affected alike, and exhibits
under the microscope no thing but free oil-globules and irregular
particles of solid, biliary matter. The liver contains but little
blood, and partly from this, but chiefly from loss of the cells, it
may be smaller than in health, and its surface wrinkled, not-
withstanding the biliary matter accumulated in it.
But destruction of the hepatic cells may take place rapidly, with-
out any obstraction of the gall-ducts, and, instead of being conse-
quent on jaundice, may be the cause of jaundice that proves rapidly
fatal, apparently from disorder of the functions of the brain.
It has been long known that cases of jaundice now and then
occur wliich prove fatal in this way ; and that in such cases it fre-
quently happens that no obstruction can be found in the gall-
ducts, — wliich are pale and empty of bile, — and no effusions cha-
racteristic of inflammation in any part of the liver. In some
such cases, no change of structure has been remarked in tho
liver, and the disease has been described as fatal jaundice from
suppressed secretion. In other cases, tho liver has been found
unusually small, and much softened, and changed in colour, and
the disease has been spoken of as softening of the liver, or
simple softening , or black softening, according to the colour of
the liver in tho individual case.
198
SUPPRESSED SECRETION OF BILE.
The two following cases, published by Dr. Alison, in the Edin-
burgh Medical and Surgical Journal for 1835, are good examples
of this terrible form of disease.
Case. — Occasional complaint of pain and heat in the abdomen, with thirst and
chilliness, for seven weeks ; then jaundice, followed at the end of two days
by delirium — No tenderness of abdomen, or fever — Occasional singultus —
Stools bilious — Coma — Purpuric spots on the skin — Death ten days from the
occurrence of jaundice — Liver of a light yellow, smaller than natural, flabby
— Mucous membrane of the ducts unnaturally white.
Peter Schread, aged about 25, a German sailor, was admitted into the
clinical ward, the 26th of February, 1826, in a state of complete delirium,
with tendency to violence, but alternating with drowsiness. His skin and
the tunica conjunctiva of the eyes were of a bright yellow colour ; he had no
tenderness of abdomen; his pulse was 60, of irregular frequency; tongue
moist ; extremities rather cold ; he had occasional singultus j he passed a
copious bilious stool, and also urine in bed soon after his admission.
His companion reported, that he had a severe attack of flux, in Java, in
the summer previous, — that he had been in good health at Antwerp, from
September till December, but that since the 1st of January, when he arrived
at Leith, he had complained often of pain and heat in the abdomen, chiefly
towards the right side, with thirst and chilliness, — that eight days before
admission he had become jaundiced, and two days before admission had be-
come delirious.
His head was shaved, bathed, and blistered, and he had one dose of calo-
mel and several of tartar emetic, (the only medicines that could be got down,)
which produced copious bilious stools, all passed in bed ; but the delirium
passed into complete coma, with dilated pupils and stertor; his pulse rose
to 120, and became feeble : some purplish spots appeared on the skin,
and he died on the evening of the 28th, — ten days after the appearance of
jaundice.
The following account of the dissection was drawn up by Dr. C. Henry,
of Manchester, then one of the clinical clerks in the infirmary.
“ The skin and subjacent cellular tissue were universally of a bright-yellow
colour. This tinge extended also to the pericranium, and to both surfaces of
the dura mater, which was rather more vascular than natural. The other
membranes of the brain were dry and glistening. The bloody points were
somewhat more numerous than usual. There was very slight distension of
the left lateral ventricle, the contained serum not exceeding half a drachm.
That found in the right was still less considerable, and there was hardly any
at the base of the brain, which appeared somewhat vascular. The consistency
of the cerebral structure was perfectly healthy. The surfaces and central
points of the cartilages of the ribs were tinged with bile, as were the perito-
neum and pleura.
FATAL JAUNDICE.
199
“ The liver, when incised, appeared of a light yellow colour; it was smaller
than natural, its structure dense and resisting compression, but in mass it
was remarkably loose * and flexible. The calibre of the cystic duct seemed to
be in part obliterated ; but the hepatic and common biliary ducts were quite
pervious. Their mucous membrane was unnaturally white. The gall-bladder
contained a greenish viscous semi-fluid matter.
“ The spleen was somewhat firmer than natural. The pancreas was healthy.
The contents of the intestinal canal were tinged, though slightly, by a greenish
bile ; those of the lower part of the ileum less than of the larger intestines.
There was no vascularity of their lining membrane, but that of the great in-
testines appeared somewhat thicker than usual. The mucous coat of the
bladder had acquired a deep yellow tinge, and contained urine of similar
appearance.”
Case. — Mental distress — Jaundice, with occasional pain at the epigastrium,
but little constitutional disturbance — Eighteen days after, drowsiness, inco-
herence, followed by coma and partial spasms — Death, three weeks from ap-
pearance of jaundice — Liver small, soft, and of a peculiar brownish-yellow
colour — Gall-ducts pervious, and almost completely empty of bile.
Agnes Anderson, aged 35, was admitted into the clinical ward, on the 10th
of December, 1830, with symptoms of jaundice, (of a fortnight’s standing,)
and occasional pain across the epigastrium, but little constitutional disturb-
ance. She bad recently suffered much mental distress, having been aban-
doned by a man with whom she had cohabited, and was in a state of agita-
tion, and, being apprehensive of catching fever, she suddenly left the house
the same day. After this, as we subsequently learnt, the pain at the epigas-
trium increased; on the 14th, she was observed to stagger in walking, and
became drowsy and occasionally incoherent, without complaining of head-
ache. On the 17th, she was re-admitted, deeply jaundiced and perfectly
comatose; her pulse was 118, soft; the surface rather cold; the respiration
somewhat stertorous, but of natural frequency ; the pupils somewhat dilated ;
the teeth firmly closed, and inclosing the apex of the tongue, which was
bleeding. There was no rigidity of other muscles ; she had occasional fits
of hurried breathing with partial spasms, during which the pupils became
quite immoveable. Her bladder was much distended, and five pounds of
deep yellow-coloured urine were drawn off by the catheter.
Blistering and enemata were tried without any effect. The breathing be-
came more rapid and heaving, and the pulse feebler, and she died twenty-
four hours after admission, — three weeks after the first appearance of
jaundice.
* In Dr. Alison’s paper, it is printed “ large and flexible,” which, con-
sidering what goes before, does not make sense. “ Large ” is probably a
misprint for “ loose.”
200
SUPPRESSED SECRETION OF BILE.
The following report of the appearances on dissection was drawn up by Dr.
J. Reid, then clinical clerk.
“ The skin had assumed a deeper tinge of yellow since death. Upon re-
moving the skull-cap, the dura mater was observed to have also a yellowish
tinge. The veins upon the surface of the brain were somewhat tinged.
There was no effusion under the arachnoid, or at the base of the brain ; but
a small quantity of yellowish serum was contained in the ventricles. Upon
cutting the brain in thin longitudinal slices, every part of it appeared quite
healthy, and nothing presented itself about which there was the slightest
doubt, except the appearance of the choroid plexus, which was of a dark red
colour, and a vein distended with blood was seen running along each of its
portions situate in the lateral ventricles. Along with the red points which
usually appear upon the cut surface of the brain, a little yellowish serum
exuded.
“ The liver was small, soft, and of a peculiar brownish-yellow colour.
The gall-bladder was collapsed, and contained a small quantity of bile. All
the bile-ducts were of the usual colour, at no point more dilated than another,
perfectly pervious throughout, and almost completely empty of bile. It was
doubtful whether the mucous membrane of the duodenum was very slightly
thickened, or not ; but there was certainly no decided change upon it.’’
Most medical men who have been some years in practice have
probably witnessed this form of disease. More than one instance
of it has fallen under my own notice, but they occurred when I
was not sufficiently alive to their interest, and my notes of them
are very imperfect. I shall not therefore relate them, but cite,
instead, the two following cases, which were published by Dr.
Bright, in an excellent paper on jaundice, in the first volume of
Guy’s Hospital Reports ; and which are counterparts of the cases
already quoted from Dr. Alison.
Case .—Abdominal pain — Jaundice — Tenderness at the epigastrium — Occa-
sional sickness — Three weeks after the appearance of jaundice, indistinct
utterance, and loss of power in the left hand, soon followed by coma and
death — Liver very small, soft or flaccid, and of a reddish-yellow colour —
No marks of inflammation on the capsule or in the ducts, which were not even
stained with bile ■ — Brain congested.
Sarah , aged 28, was admitted into Guy’s Hospital, as a surgeon’s
patient, on the 6th of August. She was a married woman, and had borne
two or three children ; but had latterly been separated from her husband,
and was said to be much addicted to drinking. As she had sores of a very
suspicious character, she was ordered to take sarsaparilla three times a day,
with five grains of the compound ipecacuanha powder, and of the Plummer’s
FATAL JAUNDICE.
201
pill, every night, which she continued for a considerable time. On the 13th
of November, I was requested to take charge of her, as she was apparently .
very ill; had been complaining of abdominal pain for the last week; and
during the last two days had become jaundiced. I found the bowels rather
confined ; urine tinged with bile; pulse moderate, but quick ; slight tender-
ness at the pit of the stomach.
(Fourteen ounces of blood were ordered to be drawn by cupping from the
region of the liver; the belly to be fomented; five grains of mercury with
chalk to be taken immediately, and jss. of castor oil four hours after, and to
be repeated until the bowels should be relaxed.)
1 4th. There is still some tenderness on pressure at the pit of the stomach,
and accelerated pulse.
(Fifteen leeches to the pit of stomach ; the mercury with chalk, and the
castor oil, to be repeated.)
The yellowness increased; the stools continued of a pale clay colour; the
tenderness of the upper part of the abdomen continued.
It is unnecessary to give a detail of all the daily symptoms. Cupping,
mercurial purges, and blue pill, with fomentations, were continued ; and dur-
ing ten days, no very remarkable change occurred.
24th. Slight tenderness over the whole abdomen ; colour very intense ;
pulse, 96, small, and rather sharp; respiration, 27 ; bowels confined; thirst;
occasional sickness ; and occasional pains in the abdomen, much relieved by
the fomentation.
28th. She generally prefers the sitting posture in bed. Lips dry; tongue
moist and red ; some sluggishness in her mode of speech, and a plaintive tone ;
pulse, 88 ; no sickness ; six or seven loose dejections.
(Twelve leeches to the pit of the stomach; a linseed poultice to the
belly.)
29th. One copious lumpy white stool. Pulse, 96 ; slight tenderness of
pit of stomach; respiration tranquil; tongue moist, but more red at the
edges.
December 1st. Her pupils are rather dilated; her mode of utterance is
dull and indistinct ; complains of loss of power in the left hand ; the right is
already disabled by disease.
2nd. Is lying on her right side, drowsy, with her legs drawn up, moving
her left hand with a kind of jactitation, often raising it to her head ; she is
capable of being so far roused as to put out her tongue when pressed to do
so. Tongue moist, and red at the edges : the pupils are dilated.
(A blister to the crown of the head ; a cathartic enema.)
3rd. Yesterday evening, she was screaming, loudly, with her tongue pro-
truded between her teeth. To-day, she is in a state of perfect coma, with the
eyes turned up. She is incapable of being roused, and has taken no nourish-
ment or medicine since yesterday.
She died the following day.
Sectio cadaveris. The colour of the whole body of the brightest yellow
which jaundice yields. Not less than an inch of adipose matter over the
202
SUPPRESSED SECRETION OF BILE.
whole abdomen. On removing the calvaria, the dura mater was found
tinged of a brilliant yellow colour, and very vascular ; raising this, the sur-
face of the brain showed the vessels loaded with blood; and beneath the
arachnoid, in the convolutions, lay a small quantity of serum, probably not
more than natural, of a decidedly yellow colour. As the brain was sliced
away, numerous points of fluid blood appeared; and from many of them the
serum which issued with the blood was of a bright camboge yellow, present-
ing points of that colour mingled with red points. The whole of the vessels,
and the sinuses of the brain, were unusually loaded with blood : the ven-
tricles unnaturally dry : scarcely could a drop of serum be discovered. The
heart healthy. The pulmonary and other vessels deeply tinged with bile. The
peritoneum, also, was peculiarly dry. The omentum beautifully spread over
the viscera. The colon, when the omentum was turned back, was seen con-
tracted, and very yellow ; while the portion of the omentum, closely attached,
was spotted with ecchymosis, and loaded with fat.
The liver weighed only two pounds five ounces. It was soft or flaccid to
the touch ; quite free from any mark of peritoneal inflammation. Its ex-
ternal appearance was mottled dark-red liver-colour, with yellow stone-
colour. The acini were pretty distinctly to be traced throughout— red at
their centres, and yellow in their circumferences; and in most parts the
yellow bore a large proportion to the whole. The gall-bladder was con-
tracted ; and contained about half a drachm of mucus, very slightly tinged
with green. The ducts were all pervious and healthy, and were not even
stained with bile. Pancreas, quite healthy. Spleen, large. Kidneys re-
markably lobulated, and tinged throughout with bile, particularly the mem-
brane lining the pelvis. Ovaries, externally very yellow. Uterus, also yellow,
with some ecchymosis in its fundus.
Case. — Jaundice — Inactivity — At the end of a fortnight, vomiting, and deli-
rium, soon followed by coma and death — Liver unusually small, and of a
brightish yellow colour, marked with purple or deep brown — Gall-bladder
small and collapsed — No trace of bile in the common or hepatic duct — The
quantity of serum within the skull unusually small — No structural lesion of
the brain.
Keatrina Pfifrein, aged 18, was admitted into the clinical ward, January
11th, 1832, labouring under icterus. She was an assistant to a German
broom-maker, and was unable to speak any English. The skin was of a
brilliant yellow; and the cheeks, which were flushed, were of the colour of
a very ripe apricot; she appeared exhausted; and though she answered
questions pretty readily, we were cautioned by a woman who brought her,
that her replies were incorrect. Pulse 120, very small and weak; feet and
body very cold. We learnt, that when she came to London, about a fort-
night ago, she had been already unwell about a fortnight ; and her skin had
a decidedly yellow tinge, which had daily increased, attended with an in-
activity amounting almost to torpor ; so that, when removed from her bed,
and placed by the fire, which was all she could bear of late, she sat con-
FATAL JAUNDICE.
203
stantly in a kind of doze. We were told that her bowels had been relaxed,
without much abdominal pain; and she had not suffered fiom sickness.
She had complained but little of headache; tongue moist, and slightly
furred; the papillae prominent.
She was ordered a moderate dose of Hyd. c. creta, three times a day, and
light nourishment and warmth; and should it not prove, as had been
stated, that her bowels were relaxed, 6he was to take some colocynth pills at
night.
Jan. 12th. — She was sick yesterday evening, vomiting a good deal ; she
lay in a perfectly torpid state the whole night, apparently suffering no pain ,
but towards the morning became delirious, so that it was with difficulty she
could be restrained in her bed. At the time of the visit she was veiy rest-
less, and seemed to suffer pain ; but was unable to answer any questions ;
indeed, except that she swallowed what was given to her, she seemed
scarcely conscious ; and it was quite uncertain whether pressure on the
abdomen gave her any pain. The pupils were dilated ; the bowels had not
been open, although she had taken two compound colocynth pills : pulse 106,
thrilling, and compressible ; tongue moist and clean.
She was ordered two grains of calomel every two hours, and the ammo-
nia julep every four hours; besides wine, if she became more depressed.
Her head was shaved, and a blister applied over the livei ; mustaid poul-
tices to the feet ; and camphor mixture was to be given freely, in case the
delirium should return ; injections were to be repeated till the bowels acted
freely.
During the night, the purging injections, with colocynth and castor oil,
were administered three times ; she lay completely comatose the whole
night ; the pulse sometimes at 140, and extremely weak, when not raised by
stimulants.
No dejection having been passed at ten o’clock in the morning, another
colocynth injection was administered, which produced copious, rather dark,
unhealthy, feculent motions, mixed with some sanguinolent fluid ; and there
was likewise an appearance like pus. The blister discharged very abundantly ;
the urine was passed involuntarily, and in considerable quantity ; mouth and
lips covered with sordes ; pulse 120, weak.
A blister to the crown of the head ; the calomel to be repeated.
She continued to sink during the day, and died at ten o clock in the
evening.
Sectio Cadaveris. — The whole external surface of a deep yellow colour ;
the adipose matter was also yellow, as were the cartilages of the libs.
The lungs were healthy, but the posterior portions gorged with blood,
probably the result of her having been lying for two days on the back.
The pleura of the left lung of a slight yellow tinge ; the heart healthy.
The whole of the abdominal viscera, when first exposed to view, were
remarkably tinged with bile; the stomach of a vivid yellow; the intestines
looked green ; the liver was unusually small, and, for the most part, oi a
brightish yellow colour, with portions marked with purple or deep brown ;
204
SUPPRESSED SECRETION OF BILE.
and, in parts, a finely spotted appearance was yielded by the acini. On
cutting into the liver, the same yellow colour, with fine dark spots, per-
vaded it. The gall-bladder was very small and collapsed, and contained
less than a teaspoonful of thick ropy mucus, of a bright green colour. The
cystic duct appeared to be quite contracted ; so that neither could a fine
probe, nor the point of a scissor, be carried along more than two-thirds of
its length upwards ; nor could the tenacious mucus of the gall-bladder be
forced down it. However, there was no appearance of thickening, or of
morbid deposit, either within or around the duct, which, when laid open
with the scalpel, presented the corrugated valvular appearance peculiar to
that part of the duct. The lower part of the cystic duct, as well as the
whole of the hepatic duct, and the common duct, quite into the duodenum,
were pervious, and not at all thickened nor diminished from the natural
calibre. There was no trace of bile in either of the ducts ; and, following
the hepatic ducts quite into the substance of the liver, no bile was detected ;
but, on squeezing the liver, the small secondary and tertiary subdivisions of
the ducts were seen filled with thick tenacious mucus, of an exceedingly
faint lemon- yellow colour.
The mucous membrane of the alimentary canal was perfectly healthy, but
the contents were very unnatural ; in some parts of the ileum and jejunum
there was yellow mucus ; in others, an olive-green mucous excrement ; and
in the colon, a drab-coloured and grey mass, characteristic of that which
usually composes the faeces of jaundiced patients.
The spleen soft ; pancreas healthy. Kidneys tinged throughout with bile.
Bladder somewhat distended, rising to view above the pubis, and contain-
ing, probably, a pint of clear yellow urine.
The thoracic duct quite empty. The arteries deeply tinged with bile.
The dura mater was of a brilliant yellow colour ; the arachnoid not vas-
cular, and quite untinged with bile; there was no unnatural effusion of
serum beneath it ; but the small quantity which collected in a few of the
sulci was very slightly tinged with yellow, as were the few drops which col-
lected in the base of the skull, when the brain was removed. When slices of
the brain were taken horizontally, a moderate number of cut vessels were
seen : many of the small points of blood gave a stain of beautifully yellow
bile around them ; and some points gave out the yellow serum, without any
blood appearing. The ventricles contained an unusually small quantity of
serum ; and that was not tinged with bile. The quantity of serum through-
out the whole brain was decidedly deficient. There was no structural lesion
nor irregularity in the brain.
Rokitansky, in his elaborate work on Morbid Anatomy, has
described this condition of the liver, under the term, yellow
atrophy. He says : “ The yellow atrophy is distinguished by a
deep yellow colour; imbibition of the whole tissue of the organ
with bile ; great relaxation or softening ; loss of the normal lo-
bular structure ; rapid diminution of volume and flattening.
FATAL JAUNDICE.
205
Appears, generally, in early life, in adolescence, and in the prime
of life. Is distinguished, during life, by its acute course ;
extreme pain of the liver; nervous symptoms and jaundice; and
finally, a fatal issue amid fever, symptoms of blood-poisoning,
irritation of the brain and its membranes, hydrocephalic softening
of the brain, exudation and softening-processes, generally, and
especially of the mucous membranes ; pneumonia, &c. The
blood in the larger vessels of the liver is thin fluid, of a dirty
red-brown ; the coats of the vessels stained yellow. The peculiar
glandular substance is melted away, and lost in the biliary colli-
quation. ( G alien — colli quation.) In the intestine, there is a
deep yellow biliary matter, sometimes black and tarry, from escape
of the poisoned blood through the mucous membrane.”
I had been for some time looking out for an instance of this
form of disease, wishing to examine the liver minutely, when an
opportunity of doing this was afforded me by Mr. Busk, who at
once obseiwed that in the portions of the liver that were most
diseased, the cells were completely destroyed.
The following notes of the patient’s illness were kindly furnished
me by Mr. Clapp, assistant- surgeon of the Dreadnought.
Case. — Jaundice — Constant hiccough — Pain in the region of the liver —
Stupor — Death after an illness of some days — Great softening of the liver,
and destruction of the hepatic cells — Red hepatisation of lower lobe of right
lung — Large ulcer in the larynx — Ruga of the large intestine of a purple
colour, and covered with lymph.
Abdul, a Lascar, set. 50—60, was admitted into the Dreadnought, the
16th of January, 1844, jaundiced, and with constant hiccough, which was
stated to have lasted for three days.
He was in a state of half stupor, and hut little concerning his feelings
could be elicited from him. He appeared, however, to have some pain in
the region of the liver, but there was no tumor in that situation. A few
hours after his admission, Mr. Clapp observed his pupils to be much con-
tracted, and, from his look, suspected that he had taken opium ; and, on
searching his clothes and bed, a small tin box containing opium was found.
No cough or other symptom of pulmonary disease was observed ; and the
hiccough continued the only prominent symptom to the time of his death,
which happened on the 18th.
The body was examined on the 20th, about forty hours after death.
The rigidity of the muscles was nearly gone. The surface was deeply
jaundiced. No hardness or fulness in any part of the abdomen.
206
SUPPRESSED SECRETION OF BILE.
The head was carefully examined, hut no morbid appearance noticed,
except the yellow tint of jaundice.
Chest. — The right lung adhered slightly to the diaphragm, in a small space
at the centre of its base, and the greater part of its lower lobe was in a state
of red hepatisation. The other lobes of this lung were congested, and infil-
tered with red frothy fluid. The small bronchial tubes were filled with a
thin mucous fluid, brownish, and also tinged with bile. The left lung was
nowhere adherent to the pleura costalis. Its lower lobe was of a dark
purple, from extreme congestion, but was not solid. The upper lobe slightly
congested, but not otherwise altered. There was no fluid in either pleural
cavity. There was a large irregular superficial ulcer on the back of the
larynx, just below the base of the ai'ytenoid cartilages, and the mucous
membrane over the cartilages was slightly raised by effusion into the areolar
tissue beneath it. The ulcer was surrounded by a narrow vascular zone.
The mucous membrane of the trachaea and bronchi was injected, and the sur-
face covered with thin brown mucus.
Heart, large and fat. Valves perfect. Muscular substance coloured in parts
by bile. Left cavities empty. Small fibrinous clots, coloured with bile, in the
right cavities. Blood, grumous and clotted.
(Esophagus, pale, and healthy throughout.
Stomach- — Mucous membrane greyish and ‘ mammillated everywhere of
natural thickness and firmness. Duodenum perfectly natural, as was also
the small intestine, to within a few feet of the lower end of the ileum,
below which it exhibited a few vascular patches, and some serous fluid was
infiltered in the submucous tissue.
The ileo-ccecal valve at first sight appeared to be slightly ulcerated, but on
looking closer, this appearance was found to be caused by the edges of the
folds of the mucous membrane being of a dark purple from congestion, and
having shreds of lymph on the surface.
Large intestine — Mucous membrane having the edge of the ruga; of a
deep red, and with small shreds of lymph on their surface, but every-
where else of natural colour, thickness, and consistence.
There was no bile in any part of the intestinal canal, nor did the mucous
membrane appeared jaundiced in any part. A large quantity of faecal matter,
of a pale clay colour, was found in the large intestine.
The kidneys were jaundiced, but otherwise perfectly natural. Bladder
empty.
Spleen, large, firm, rather pale.
Pancreas, healthy.
The liver was rather large, and weighed four pounds four ounces. The
whole gland, except a very small portion of the extreme right, was remark-
ably soft, flabby, and easily torn. This condition was most marked in the
lobulus spigelii and adjacent parts. There was no disease in the gall-
bladder or ducts, which were carefully examined, nor any obstruction at
the duodenal orifice. The bile could be very readily made to flow into the in-
testine. The gall-bladder contained about an ounce of thick bile sparkling
with distinct scales of cholesterine, but otherwise of natural appearance.
DESTRUCTION OF THE HEPATIC CELLS.
207
On examination by the microscope, Mr. Busk found that in the firm
portion, the proper cells of the liver contained a good deal of bile, hut were,
otherwise, quite natural ; while in the softened portion, there were hardly any
cells to be found. Nothing was seen but a confused mass of amorphous
particles and oil-globules .
These different appearances are exhibited in the annexed wood-
cut. (a) represents cells from the firm
portion of the liver. The dark spots
within them are particles of biliary
matter, which was in greater quantity
than usual. Some cells contain small
oil -globules, marked by the clear rings.
Between the cells are seen small free
oil-globules and particles of granular
matter, (h) the appearance presented
by a particle from the softened portion
of the liver, showing an irregular aggre-
gation of oil-globules, particles of solid
biliary matter, and amorphous granular
matter.
Mr. Busk sent me the liver to examine, and I was enabled to
satisfy myself of the accuracy of the description of the microscopic
appearances he sent with it, as given above. All I observed, be-
sides, was that the firm portion was hardly so firm as is natural,
and was of a mottled, yellowish, nutmeg, appearance, the lobules
being distinct to the eye. The soft portion was of a uniform
dirty colour, a compound of yellowish-brown and red, and pre-
sented no appearance of lobules. It had no smell of gangrene.
It may, perhaps, be supposed, from the time after death at
which the body was examined, that these changes resulted from
decomposition ; but it was clearly not sp. The hepatic cells do
not alter quickly after death. In ordinary cases, they present no
such appearances as those described, much later after death, and
in the solid part of this liver, which was kept, and several times
examined by Mr. Busk and myself, the cells were distinctly visible
two days afterwards.
Destruction of the cells took place, without doubt, during life,
find was probably the causo of the jaundice, which cannot be other-
208
SUPPRESSED SECRETION OF BILE.
wise accounted for than by want of action on the part of the cells,
for there was no impediment to the flow of bile through the ducts.
A portion of the liver still continued to secrete bile, which flowed
into the intestine.
In this case, the cells were broken down, just as they were in
the case of Mrs. Diprose, before related, in which this change was
a remote effect of closure of the common gall- duct, hut the con-
dition of the liver in the two was in many respects different.
1st. The liver was here readily torn or broken down by the
Jinger, while that of Mrs. Diprose, though feeling equally flabby,
was not.
2nd. The softened portion of the liver was brown or reddish-
brown, and not much coloured with bile ; while, in Mrs. Diprose,
the liver was throughout of a deep olive, mottled with yellow,
solely from the presence of bile.
3rd. The liver seemed to contain more fluid, certainly contained
more blood, than that of Mrs. Diprose ; and, under the microscope,
it exhibited more amorphous granular matter, and less solid biliary
matter, and oil.
4th. In the one case, a small portion of the liver remained
tolerably healthy, and continued to secrete bile of natural colour
and appearance ; in the other, every part of the liver was disor-
ganised.
There are still greater differences in the symptoms, and in the
state of other organs, in the two cases. The case of obstructed
gall-duct was very lingering, the patient died much emaciated,
and all organs besides the liver were sound. Here, the disease
proved fatal very quickly — and besides tins change in the liver,
there was hepatisation of the right lung, a large ulcer in the
larynx, and the folds of the mucous membrane of the large in-
testine were purple, or of a deep red, and covered with lymph.
We are ignorant of the cause of this terrible disease, and know
but little of its real pathology. The symptoms and the marks of
inflammation in various parts of the body, depend, undoubtedly, on a
poisoned, or unhealthy state of the blood ; but it is impossible to say
in what degree this results from the rapid destruction of the cells
of the liver, and the consequent jaundice; and in what degree
from the cause, whatever it he, by winch this destruction of the
cells, and softening of other tissues of the liver, is brought about.
Up to this time, such cases have been considered cases of jaundice
FATAL JAUNDICE.
209
depending, not on obstructed gall-ducts, but on suppressed secre-
tion of bile; and the changes in the liver have been overlooked, or
their outward and obvious characters only have been noticed.
It would appear that the disease is not necessarily fatal. It
happened that on the 2 1st of January, four days after the admission
of Abdul, another Lascar was brought into the Dreadnought from
the same ship, who was also jaundiced, and semi- comatose, passing
blood in considerable quantity from the bowels, and with very
evident tenderness in the right hypochondrium, but without hic-
cough or vomiting. His disease was considered by Mr. Busk to be
the same as that of Abdul, and the same issue was expected ; but
in a few days he got very much better, and soon recovered suffi-
ciently to leave the hospital. Numbers of other Lascars from the
same ship were brought into the hospital, and several of them
were observed to be more or less jaundiced, so that it is not im-
probable that these also had the same disease in a less degree. All
these men lived in the same way, and were subjected to the same
influences of diet and climate.
Many remarkable instances have been recorded of jaundice
from suppressed secretion of bile, occurring in several members of
a family in succession, and in some of them proving rapidly fatal
with delirium and coma.
The following instance was published by Dr. W. Griffin, of
Limerick, in the Dublin Journal of Medical and Chemical Science,
for 1834, in the first of a series of excellent papers, entitled,
“ Medical Problems.” I give it in Dr. Griffin’s own words :
“ A poor woman requested me to visit her daughter, Mary
Barry, aged 20 years, who she informed me had been three days
ill, and was now speechless, and she believed dying. On enter-
ing the cabin in which she lived, I saw her make a faint expira-
tion, which proved to be her last, as she was quite dead when I
reached the bed. Her skin was still warm, and universally tinged
with a deep yellow colour. The countenance was hydropic, and
the pupils were dilated. On inquiring, I found the girl’s ailment
had set in with languor and heaviness ; on the second evening she
was seized with sickness of stomach, vomiting, and appearances
of jaundice, and next morning complained much of her head.
She then looked so very ill, that her mother began to get alarmed,
and insisted on her going to the dispensary for advice ; the poor
p
210
SUPPRESSED SECRETION OF BILE.
girl shook her head despondingly, and said she was too weak to
walk there, but that she would go into the room and lie down on
the bed. These were the last words she uttered. When the
mother went in afterwards, there was an appearance of stupor
about her, from which she endeavoured to rouse her, hut could
get no reply. — She was in profound coma !
(r In about three weeks after, I was called to see Ellen Barry, a
sister of the former, and found her labouring under an affection
precisely similar. She had been attacked with languor and heavi-
ness, followed by sickness of stomach and vomiting, with universal
yellowness of the skin. She was now in imperfect coma ; consci-
ous when roused, but unable to speak, and very unwilling to be
disturbed. From this very dangerous state she was rescued by
active and continued purging ; the yellow tinge gradually disap-
peared, and in a few days she regained her usual health.
“ Within a very short period afterwards, another member of the
same family was attacked ; a boy, of about 1 3 years of age. My
brother was requested to see him, and found him moaning and
comatose ; his belly tender to the touch, his pulse slow, and his
skin of a saffron colour ; his breathing was not stertorous. This
case was more sudden than either of the foregoing ; the hoy was
seized with sickness of stomach and vomiting at night, and in the
morning was jaundiced and insensible. In this state he lay, until
nearly the end of the 2nd day, without medical aid, up to which
period his bowels had not been moved. An ineffectual effort was
then made to purge him, hut he was unable to swallow, and died
in a few hours.
“ The parents were now, it may he supposed, highly apprehensive
for their remaining children, and the event proved not -without
just reason. After the lapse of a few months, their next hoy, John
Barry, aged 11 years, showed symptoms of jaundice. He grew
languid and heavy, and in two days the tunica albuginea and skin
were of a deep yellow. There was great sluggishness of the bowels,
and slight tenderness of the abdomen, hut very little pain. He
did not complain of his head, but, like the others, was seized with
sickness of stomach and vomiting. I had early notice of this
attack, and was vigilant in looking for the supervention of coma,
although from any existing symptoms there was no greater reason
to apprehend it than in any common case of jaundice, if I except
some slight dilatation of the pupils, and sluggishness in their
FATAL JAUNDICE.
•211
movements. The boy was up and about, and did not, in fact,
appear to be very ill ; but the fate of bis brother and sister left a
lesson not to be forgotten, and I accordingly warned the mother
to give me instant notice on the occurrence of the slightest stupor
— he was in the meantime actively purged. There was little
change in him that night or the next, but on the succeeding
morning I had a messenger with me at an early hour, to say that
he had fallen into a state of insensibility in the night, and could
not now he roused. I found him quite comatose, with slow pulse,
dilated pupils, and almost a total loss of sensation and voluntary
motion. On pinching his hand severely, however, he evinced
signs of consciousness, moaning slightly, and slowly drawing his
hand away. Ten ounces of blood were immediately taken fron*
the temporal artery ; the head was shaved, and kept wetted with
refrigerant washes, and castor oil was administered every fourth
hour. As the bowels were slow in acting, injections were given
at night, and large blisters applied to the nape of the neck.
These had the desired effect. ITe was copiously purged for several
hours, and in the morning evinced signs of returning consci-
ousness ; from thenceforward there was, day after day, a steady
and progressive improvement, until his recovery became fully
established.
“ Some time after, the friends were once more alarmed by a
recurrence of the vomiting and jaundice ; but the progress of
coma was arrested, and the complaint readily removed, by purging
alone.
“ These four cases of jaundice running rapidly into coma, which
in two of them terminated in death, when we consider that they
occurred in one family, within a few weeks of one another, and
without any unusual or remarkable symptoms which could indi-
cate the impending danger, suggest a very important question
with regard to the pathology of the disease : * On what morbid
state did the occurrence of coma in these particular instances
depend ? ’ ”
Another and almost parallel instance, except that the different
members of the family were attacked after longer intervals, and that
the jaundice was attended by more fever, is related by Dr. Graves,
in his work on Clinical Medicine. The account was sent to Dr.
p 2
212
SUPPRESSED SECRETION OF BILE.
Graves by Dr. Hanlon, of Portarlington, liis former pupil, of
whose assiduity and zeal he speaks in high terms.
The cases appear to me so interesting, when taken in conjunction
with those before related, that, notwithstanding its length, I have
ventured to transcribe the account entire.
Case I. — “ Saturday, July 25th, 1840, I was called to visit Miss Maria
B , aged 17 years. On the preceding Wednesday, she complained of
languor, and in a few hours was attacked with bilious vomiting, which had
returned three or four times in every twenty-four hours since. When the
vomiting commenced, she became jaundiced, and the colour increased in its
intensity, until it assumed a greenish-yellow tint. The bowels were consti-
pated for two days before the vomiting began, and had remained so, notwith-
standing that the apothecary in attendance had given her repeated doses of
purgative medicines. Effervescing draughts and other medicines intended to
allay the vomiting had been given without success.
“ 1 found the tongue thickly coated with a yellow mucus : tenderness of the
epigastrium and hypochondrium ; thirst ; abdomen not tender on pressure ;
urine scanty and high-coloured ; pulse, 80 ; slight headache ; pupils natural ;
complains of want of sleep : and appears fretful and anxious.
“ Calomel, combined with compound extract of colocynth, aided by purga-
tive enemata, caused a small dark and offensive motion towards evening.
Leeches were applied to the epigastrium and region of the liver, followed by
stupes, three grains of calomel every fourth hour, and a purgative draught,
consisting of infusion of senna, and tincture of senna, jalap, and cardamoms,
after every second dose of calomel.
“ Sunday. — Vomited twice since yesterday evening : the bilious matter of a
darker colour ; tongue still loaded ; thirst diminished ; tenderness of epigas-
trium and right hypochondrium much less ; bowels moved twice in the course
of the night — motions larger, but still very dark in colour ; pulse, 80 ; head-
ache relieved ; pupils natural ; colour of skin the same ; slept for two or three
hours in the night; same treatment continued.
“ Monday morning, five o’clock. — I was called up in haste to visit her. It
appeared that two hours before my arrival, she complained of violent head-
ache and intolerance of light, and vomited a dark brown matter resembling
coffee grounds ; soon afterwards became very restless, and gradually fell into
a state of stupor. I found her in imperfect coma, the pupils excessively di-
lated and insensible to light, the eye-lids closed. She flung herself every
minute or two from one part of the bed to another, and uttered a faint sub-
dued scream ; she was very unwilling to be interfered with ; pulse 60, and
oppressed; skin of a still deeper tint of greenish-yellow.
“ The assistance of Dr. Tabuteau and Dr. J. Jacob was procured in con-
sultation. Fourteen leeches were applied to the temples ; the head shaved,
and cold cloths applied to it ; twelve grains of calomel in the first dose, and
five grains every second hour afterwards; purgative enemata were employed
FATAL JAUNDICE.
213
every second hour. Cold affusion on the head was subsequently used, to a
great extent, but without producing any change in the state of the pupils, or
the coma ; mercurial inunction in the region of the liver and insides of the
arms was commenced, and a large blister applied to the scalp.
“ At eleven o’clock, a.m. she was seized with violent convulsions, which
lasted about a minute, and were accompanied with shrill screams ; the right
extremities appeared more strongly convulsed than the left, the mouth was
drawn to the left side. The convulsions returned every thirty or forty
minutes with the same violence and screaming, until three o’clock, p.m., when
they became less violent, but more protracted, and gradually passed into a
continued spasm, or jerking, of the extremities. She threw up occasionally
a mouthful of dark matter like that which she had previously vomited.
The administration of the calomel was relinquished, as every attempt to give
it brought on a return of the convulsions. The mercurial inunction was
assiduously continued, but no mercurial foetor could be detected on the
breath ; the coma became more profound ; the pulse rose to 108, small,
fluttering, and finally intermitting ; sordes collected on the teeth ; the urine
and faeces passed involuntarily ; the breathing, towards the close, became
stertorous ; and she expired at eleven o’clock the following morning. No
examination of the body was permitted.”
Case II. — “ Monday, March 29th, 1841, I was requested to visit Miss
Charlotte B , aged 1 1 years, sister of the former. She had been previ-
ously healthy; for the last two days has had the usual symptoms of a feverish
cold, which is attributed to her having wetted her feet. I found the tongue
loaded; tenderness of the epigastrium, none in the region of the liver;
thirst; bowels confined; urine scanty and high-coloured; pulse, 120; no
headache; pupils natural ; no discolouration of the eyes or skin. Six leeches
to the epigastrium, to be followed by stuping ; purgatives ; diaphoretic mix-
ture and diluents prescribed.
Tuesday morning, nine o’clock. — Appears better ; slept some hours in the
course of the night; tongue cleaner ; thirst diminished; tenderness of the epi-
gastrium much less ; no tenderness on strong pressure in the right hypochon-
drium ; bowels have been strongly acted on four times ; motions dark and
offensive ; urine more copious and paler ; pulse, 92 ; no headache ; pupils
natural; no discolouration of the conjunctiva, or skin. Having been absent
from home during the day, I hastened, on my return at eight o’clock in the
evening, to visit; and was greatly surprised to find her in the same state as
her sister had been. It appeared that about three o’clock she became heavy
and languid, and the skin became slightly jaundiced. She complained of
headache and intolerance of light; vomited a dark brown matter resembling
coffee grounds ; tossed about from one part of the bed to another ; refused
to answer questions, and fell into a state of insensibility ; the bowels had been
moved twice, the motions dark, but not offensive. I found her in a state of
imperfect coma, the eyelids closed, the pupils excessively dilated, and insensi-
ble to light; pulse, 64, and oppressed; skin jaundiced. In a few minutes
after my entering the room she was seized with violent convulsions, which
214
SUPPRESSED SECRETION OF BILE.
were accompanied by shrill screams, and lasted about a minute. Pressure on
the right hypochondrium appeared to give her pain. Upon my requesting
that additional medical aid should be procured, her friends declined having
it, on the ground that the case appeared precisely the same as her sister^,
and all our efforts on that occasion had been unavailing. Under these cir-
cumstances I had recourse to the same plan of treatment as that adopted in
the preceding case : cold affusion on the shaven head ; ten leeches to the
right hypochondrium : mercurial inunction on the right side and inside of the
arms, in the intervals between the convulsions; strong purgative enema
frequently repeated, and a large blister on the scalp. The disease, quite un-
controlled by these means, pursued precisely the same course, in every parti-
cular, as the former one. The convulsions continued most violent for two
hours, when they began to be less violent, but much more protracted, until
they passed into continued twitchings of the muscles of the extremities.
The coma became more profound ; the breathing stertorous ; sordes
collected on the teeth, and she expired at seven o’clock the following
morning.
“ Her friends being now alarmed for the safety of her surviving brothers
and sisters, became very desirous that the body should be examined. Dr.
Tabuteau, who had seen the former case in consultation, assisted me in
making the examination. The following are the results : examination made
thirty hours after death ; surface of the body jaundiced.
Head. — Pacchionian glands preternaturally vascular; venous turgescence
generally over the surface of the brain, with increased vascularity of the
middle, and especially the left anterior lobes ; substance of the brain much
more vascular than usual ; great vascularity of the choroid plexus ; none of
the optic tlialami, or corpora pyramidalia ; the entire surface of the base of
the brain highly vascular, particularly at the crura cerebri, pons varolii, and
medulla oblongata; no fluid found in the ventricles.
Abdomen. — Numerous spots of extravasated blood in the omentum ; several
small patches of inflammation along the small intestines ; stomach appa-
rently healthy.
Liver. — Size, natural ; colour, externally of a dull yellow, with several
dark spots about the size of a half-crown piece; consistence, less than usual ;
structure, minutely granular, and of a very peculiar crimson-orange colour,
somewhat resembling what might be supposed to result from an intimate
mixture of arterial blood and bile ; gall-bladder distended with bile of the
usual appearance. Thorax, not examined.
I endeavoured to preserve portions of the liver in a dilute solution of
corrosive sublimate and diluted alcohol, but they gradually lost their charac-
teristic appearance in both fluids.
Case HI. — Friday, June 18th, 1841, I was called to visit Miss Jane B — ,
aged eight years ; sister of the two former. I was informed that she had
been previously healthy. This morning she appeared languid, and was
seized with bilious vomiting. No cause can be assigned for her illness. I
found the skin jaundiced slightly; the tongue loaded; tenderness of the
FATAL JAUNDICE.
215
epigastrium and right hypochondrium; thirst; bowels confined; pulse 108 ;
no headache ; no intolerance of light ; pupils natural ; urine scanty and high-
coloured. Eight ounces of blood were immediately taken from the arm,
which afterwards proved to be buffed and cupped ; eight leeches applied to
the region of the liver, followed by stuping ; twenty grains of calomel given
at once, and a strong purgative draught every fourth hour until the bowels
are fully acted on ; three grains of calomel, and one and a half of James’s
Powder every third hour after purgation ; cold to the head.
Saturday. — Slept none ; skin more deeply jaundiced ; tenderness of the
epigastrium diminished ; heat of the right hypochondrium still remains ;
tongue yellowish ; vomited twice since yesterday evening ; urine tinged with
bile, and more copious ; bowels moved four times ; motions dark and offen-
sive ; pulse 1 10 ; headache and some intolerance of light ; considerable
restlessness. Six leeches to the right side; four to the temples ; cold to the
head ; a blister to the nape of the neck ; mercurial inunction ; five grains of
calomel and one of James’s Powder every second hour. I now watched the
case with the greatest interest and anxiety.
Sunday Evening. — Slight mercurial fetor of the breath; tongue begin-
ning to clean; tenderness of the right side diminished ; bowels moved three
times ; motions less dark and offensive ; pulse 90, and soft ; headache and
intolerance subsided; restlessness entirely gone; some return of appetite.
Calomel and James’s Powder were continued every fourth hour until a
slight salivation was established, and cold carefully applied to the head.
No unfavourable symptoms subsequently appeared. The tongue became
clean, the pulse fell to the natural standard, the motions became more
healthy in appearance, the appetite returned, and under the use of four
grains of calomel at night, and a strong dose of black draught the following
morning, repeated every third night for three weeks, the jaundice dis-
appeared, and she has remained quite well up to this period.” — Graves’s
Clinical Medicine, p. 459.
The eases that have now been related all bear a certain resem-
blance to each other. In all of them, jaundice occurred, not from
any impediment to the flow of bile through the ducts, but because
no bile, or but a small quantity of bile, was secreted : — the secreting
function of the liver was suppressed. In all, too, the jaundice
was followed by delirium, or stupor, which in some soon passed
into coma, with or without convulsions. In all in which the
body was examined, the liver was found altered in structure,
and in the same way ; it was diminished in size, (in all except
Abdul), soft or flabby, and of a light yellow, or brownish-yellow,
or crimson- orange, or some kindred tint. In none of them were
any marks of inflammation noticed in the capsule of the liver, or
in the ducts. In one of the cases, where the liver was examined
216
SUPPRESSED SECRETION OF BILE.
by the microsoope, the hepatic cells were found to be in some
parts completely destroyed. It is probable, therefore, that a
like change had taken place, or was taking place, in some of the
others, where the liver presented to the eye similar appearances,
and where, from the absence of bile, it was clear that the
office of the cells was not performed. In several of the cases,
although there was jaundice, the secretion of bile teas not
completely stopped ; the matter brought up by vomiting, or dis-
charged by stool, was bilious. In Abdul, this was explained by
the circumstance that all parts of the liver had not suffered alike ;
a small part retained its lobular structure, and continued to secrete
bile.
But although the cases here brought together, present so many
points of resemblance, it must not be inferred, that the disease
under which the patients were labouring, was essentially the same
in all. Disorganisation of the hepatic cells, or suspension of their
secreting power, may, probably, be the effect of a variety of morbid
causes, essentially different from one another in character, and in
their other effects on the system.
In the second case related by Dr. Alison, and in the first of those
which I have cited from Dr. Bright, jaundice seems to have been con-
sequent on mental distress, and was probably caused by it. We
should not be justified in drawing this conclusion from these cases
taken by themselves. But so many instances have been recorded,
in which jaundice immediately followed a sudden alarm, or shock,
or other strong and depressing mental emotion, that no doubt
can remain of the influence of such emotions in producing it. Dr.
Watson, in his admirable lectures, after relating some striking
instances of this sequence of events, observes, “ There are scores
of instances to the same effect ; and this is observable of such
cases, that they are often fatal, with head symptoms : convulsions,
delirium, or coma, supervening upon the jaundice.” Morgagni, in
his 37th epistle, has related several cases in which jaundice, soon
followed by delirium and fatal coma, came on after mental dis-
tress, or fright; and in the first of these cases, which he cites
from Valsalva, the liver seems to have presented much the same
appearances as in the cases related in this chapter. “ Ventre
aperto, jecur inventum est flaccidum, et ad subpallidum vergens :
in ejus vesicula, bibs subobscura.”
In some of the other cases related above, the disease seems to
JAUNDICE.
217
have been the effect of some peculiar poison. It is difficult to
explain otherwise the occurrence of several cases of jaundice about
the same time, among the crew of a vessel ; or, at short intervals,
in the different children of a family ; more especially, when the ill-
ness attending the jaundice is so peculiar, and so uniform in cha-
racter, as it was in the instances recorded by Dr. Griffin and Dr.
Hanlon. It is worthy of remark, that the symptoms attending the
jaundice, though almost exactly alike in the children of the same
family, were in many respects different in the different families. In
the instance related by Dr. Griffin, no symptoms are noticed but
jaundice and vomiting, with languor and oppression, soon passing
into coma. In the instance recorded by Dr. Hanlon, the jaundice
was attended by other symptoms like those of a severe form of re-
mittent fever. Now and then, jaundice occurs in several members
of a family in quick succession, without beiug attended by any
alarming symptoms. An instance of this, in the family of a
clergyman, in a country parish, in Devonshire, fell under the no-
tice of my brother, Dr. Christian Budd, who has sent me the fol-
lowing account of it :
“ On the 2nd of July, 1843, I was sent for to see Miss E. B.,
set. 6, who had been for a day or two suffering from general dis-
order; slight shiverings, headache, listlessness, loss of appetite,
and restlessness at night. She had complained of no fixed pain,
and had not vomited. When 1 saw her, she was slightly flushed,
her skin was hotter than natural, pulse rather frequent, but not very
so, tongue furred ; she complained of headache, had a dull heavy
look, and rested her head continually on the sofa, or a chair. She
had no appetite, and not much thirst. I observed nothing pecu-
liar in the colour of the skin. I ordered a purgative, — mercury and
chalk, and senna. The senna, she vomited. The next day, her
skin was manifestly yellow, urine porter- coloured, and motions
clay-coloured. I gave her gentle purgatives, and she soon got
well. Her skin, however, remained yellow for some little time
after.
“ The last day or two of the same month, her elder sister, ait. 1 0,
fell ill in the same way, and on the 3rd of August, I visited her.
Her symptoms were precisely the same as those just detailed, and a
yellowness of the skin could already be discerned. The next duy,
she was completely jaundiced. Her convalescence was much
218
SUPPRESSED SECRETION OF BILE.
slower than that of her sister, and she remained yellow much longer.
Before she was quite well, her brother, set. 11, went to London
with his father, but the day after his arrival there, complained of
being very poorly; was listless, took no notice of the sights around
him, sat down whenever and wherever he could, and ate nothing.
This state was at first attributed to the fatigue of the journey, but
in a short time he also became jaundiced. His convalescence was
more rapid than that of his sisters. He took, I believe, some
purgatives merely, and soon got well.”
Other instances have come to my knowledge of jaundice occur-
ring in several children of the same family, or in several persons
living in the same locality, in quick succession, without being
attended by any unusual or alarming symptoms.
In all these instances, the disease was limited to a small spot,
so that it cannot be ascribed to a peculiar state of the general
atmosphere. The miasm, or whatever it was that caused it, had a
local origin.
Another reason for believing that the jaundice in these cases
was the effect of some poison, is, that jaundice of the same kind,
that is, from suppressed secretion, occurs in other diseases, that
obviously depend on poisoning of the blood. I have met with
two instances in which slight jaundice occurred in purulent
phlebitis, with scattered abscesses in various parts of the body,
and obviously in consequence of suppressed secretion. There was
no obstruction in the ducts, and the gall-bladder contained a pale
citron- coloured fluid. In one of these cases, I remarked that the
liver was extremely soft. In neither of them were there abscesses,
or other marks of inflammation, in the liver.
Jaundice, with pain at the stomach, and vomiting, is one of
the effects of the poison of serpents ; and is produced, it would
seem, not by obstruction from inflammation and closure of the
gall-ducts, but by suspension of the secreting power of the liver
under the influence of the poison.
Jaundice occurs, too, in some malignant forms of fever, ob-
viously produced by the action of a poison. The yellow fever, which
owes its name to the concomitant jaundice, has many points of
resemblance with some of the cases before related, especially those
recorded by Dr. Hanlon. In Dr. Hanlon’s cases there was bilious
vomiting, with pain at the epigastrium, and fever, and jaundice,
JAUNDICE.
210
followed by the vomiting of altered blood, which is so cha-
racteristic of the yellow fever of the West Indies. In these
cases, too, as in yellow fever, the Mach vomit proved the har-
binger of speedy death. Epidemics of a peculiar form of
fever, of which vomiting and jaundice were frequent symptoms,
have at times prevailed in certain districts of this country. A
fever of this land was epidemic in Glasgow in the summer of
1843.
In the cases of fatal jaundice related in the first part of this
chapter, which occurred singly, we have not the same clue to
the nature of the cause by which the jaundice and other symp-
toms were produced. In some of them the exciting cause was
evidently a purely nervous influence : in others, the disease might
have been the effect of some noxious matter, either introduced from
without, or engendered by faulty digestion or assimilation.
It appears from some of the instances that have been adduced,
that this form of jaundice is not necessarily fatal, even after the
patient has fallen into a state bordering on coma. The ship-mate
of Abdul, whose disease was, undoubtedly, of the same nature as
his, was brought into the hospital jaundiced, semi-comatose, and
passing blood in considerable quantity from the bowels, but yet
recovered. Of the four children of the same family whose cases
are related by Dr. Griffin, two recovered — one, after being in im-
perfect coma, conscious when roused, but unable to speak ; the
other, after being quite comatose, with slow pulse, dilated pupils,
and almost total loss of sensation and voluntary motion.
It is impossible to say what amount of damage had occurred
in these cases ; or whether in them the cells in any part of the liver
had been completely destroyed, as in Abdul. Still less, therefore,
can it be determined, what are the ulterior effects of the disease,
where recovery takes place. It may be, that the cells are not
necessarily disorganised, and that in favourable cases they resume
after a time their healthy action ; or, if some of the cells
be disorganised, others may be generated from those that remain,
— just as blood-cells form in persons who recover from losses
of blood or from chlorosis ; or, the disease may end in flat-
tening and atrophy of a lobe ; an alteration, which is now and
then met with, and is generally supposed to be congenital ;
or, the liver may remain long after, perhaps ever after, somewhat
220
SUPPRESSED SECRETION OF BILE.
altered in appearance and texture, as seems to happen after severe
forms of remittent fever.
But disorganisation of the liver, which, as far as can he judged
of by the naked eye, is of the same kind as in the cases before
related, now and then occurs, and proves fatal from mere exhaus-
tion, without delirium, or coma, or convulsions. In proof of
this, I may cite the following case from Abercrombie, who calls the
disease “ black ramollissement of the liver,” to express, as he says,
the change in the colour and texture of the liver, without imply-
ing any opinion as to the nature of the disease.
Case. — Sudden occurrence of deep jaundice — Nausea, but no fever or other
complaint — Afterwards, frequent vomiting of black mattei — Death from ex-
haustion, after an illness of about three weeks — Liver, one-third of its natural
size, of very dark colour, extremely soft, and apparently disorganised — Gall-
bladder, empty and collapsed.
A lady, aged about 50, of a full habit and florid complexion, was suddenly
seized in the beginning of June, 1821, with very deep jaundice, for which no
cause could be traced. There was no pain, no tenderness, and no fulness,
in the region of the liver ; the pulse was natural, and rather weak ; there was
little appetite, and some nausea, but no other complaint. The bowels were
easily moved, and the motions were dark or brownish. After the free use of
purgatives, &c., she began to take a little mercury. For a week after this,
she seemed to be improving, but she then became more oppressed, with
frequent complaints of nausea, and a feeling of languor ; the tongue was
white, but the pulse was natural. No other symptom was complained of, and
nothing could be discovered in the region of the liver.
On the 16th, she began to have some vomiting, which occurred occa-
sionally for three days, without any other change in the symptoms, until the
19th, when streaks of a black substance were observed in the matter which
was vomited. The vomiting now became more and more urgent, with in-
crease of the quantity of this black matter, and she died, gradually exhausted,
on the morning of the 2 ] st.
Inspection. — The liver was reduced to little more than a third of its
natural size ; it was of a very dark, almost black colour, and internally soft
and disorganised, like a mass of coagulated blood. The gall-bladder was
empty and collapsed. The stomach and bowels contained a considerable
quantity of black matter, similar to that which had been vomited, but were
in other respects quite healthy. — Diseases of the Stomach, &c., 2nd edition,
p. 361.
Softening and discolouration of the liver, with partial suppres-
SOFTENING OF THE LIVEIl.
221
sion of bile nnd jaundice, — the result probably of destruction of
the cells, — may take place more slowly, and though fatal in the
end, may at first he marked by no urgent symptoms.
In proof of this I may cite the following case related by
Andral. (Clin. Med. iv. p. 322.)
Case. — Indigestion — Gradual loss of flesh and strength, sense of weight at the
epigastrium — Urine and sweat tinged with bile, but no jaundice— Great ema-
ciation— Death, after an illness of two years— Liver, pale, extremely soft — No
bile in the gall-bladder or ducts, which were healthy — No disease of the intes-
tinal canal.
A shoemaker, 58 years of age, had begun to grow thin and weak, and to
digest ill, about two years before he entered La Charite. He had had no
pain at the epigastrium, or in any other part of the belly ; no vomiting or
nausea ; but loss of appetite, at first occasional, afterwards constant, with
uneasiness and a sense of weight about the lower and right part of the epi-
gastrium, five or six hours after eating. He took to his bed a month only
before he entered the hospital.
At the beginning of his illness and during its course, leeches had been
many times applied to the epigastrium, but never gave him any relief.
On his admission to the hospital, the tongue was very pale, but not
otherwise remarkable. There was no bad taste in the mouth. The epigas-
trium was soft, and, as well as the rest of the abdomen, free from pain.
The patient had for some time lived solely on milk, which agreed well
with him. There was no yellowness of the skin or conjunctiva, but the
bowels were confined, and the motions white, as in jaundice. The
urine, which was tolerably abundant, had a very striking orange colour, as
in jaundice. Lastly, the patient sweated often about the head, and linen
wetted with this sweat, was stained yellow. The pulse was habitually rather
frequent, without heat of skin. The emaciation was considerable. The
patient was supposed to labour under chronic gastritis, complicated with
some disease of the liver, which was inferred from the characters of the stools,
the urine, and the sweat.
He remained in the hospital two months, at the end of which he died,
without agony, in a state of great exhaustion. The symptoms underwent no
change, except that he grew weaker and thinner. Milk, which he took at
first with sufficient relish, was soon objected to, and he had afterwards the
most complete disgust for every kind of nourishment. He asked for wine
so pressingly, that it was given him. It did not aggravate the gastric
symptoms. The treatment consisted in the application of a blister to the
epigastrium, with simple emollients internally.
On examination of the body, the mucous membrane of the stomach was
found white, without any injected vessels, and it had everywhere its natural
222
SUPPRESSED SECRETION OF BILE.
thickness and consistence. There was no appearance of disease in the duo-
denum, or in the rest of the intestinal canal.
The liver, on the outside, was pale. On being drawn gently from its
place, it was torn ; and by the pressure of the finger its tissue was broken
down into a greyish pulp. It had throughout the colour of dead leaves, and
when cut across or pressed, hardly any blood escaped. It did not, however,
grease the scalpel, and had a very different appearance from fatty liver.
In the gall-bladder, instead of bile, there was a colourless serous liquid,
which was not bitter. There was nothing remarkable in the hepatic, cystic,
and common ducts, which were empty of bile.
In this case, the change in the appearance and texture of the
liver seems to have been much the same as in the cases before
related, and, as in them, the secretion of bile was suppressed. It
was clear that the suppressed secretion was owing primarily to want
of action on the part of the hepatic cells, for the biliary passages
were quite free ; and it was also clear from the frangibility and
softness of the liver, that the nutrition of the other elements of its
structure had suffered as well. This disease seems to be quite dif-
ferent from inflammation. The man’s illness did not set in with in-
flammatory symptoms ; leeches, several times applied to the epi-
gastrium, produced no relief ; and none of the usual traces of in-
flammation were remarked after death. The morbid change appears
more nearly allied to gangrene than to inflammation ; and was
probably here caused by some noxious product of faulty diges-
tion, which, being carried to the liver in the portal blood, directly
impaired the vitality and nutrition of its tissues. The uneasiness
felt some hours after eating, and the gradual loss of flesh and
strength, are sufficiently accounted for by the disorder of diges-
tiou and the suppression of bile. In this case, the patient pro-
bably lived longer than he otherwise would have done, and suf-
fered less, in consequence of there being no jaundice, which was
probably prevented by the colouring matters of the bile passing off
freely by the kidneys and skin.
The following case, also related by Andral, (Clin. Med. iv. 326,)
seems to have been another instance of the same disease.
Case. — Difficult digestion — Complete loss of appetite — Occasional vomiting
— Scanty secretion of bile — Great emaciation — Liver remarkably pale and
soft — Gall-bladder and ducts free, hardly stained with bile — A large ulcer in
SOFTENING OF TIIE LIVER.
223
the stomach — Follicles of the colon enlarged — Intestinal canal in other respects
healthy.
A woman, 50 years of age, had suffered from difficult digestion for many
years. Her appetite had gradually diminished, and, when she entered the
hospital, was quite gone. She vomited occasionally, but had no pain at the
epigastrium. The belly was everywhere soft, and free from pain. The
tongue was natural. The bowels were confined, and the stools ash-coloured.
The emaciation was considerable ; the pulse not quick. The colour of the
urine was not noticed. Some time after her admission to the hospital, her
tongue became red and dry, her pulse frequent, and she died in a typhoid
state.
The liver, extended into the left hypochondrium, but not below the carti-
lages of the ribs. Its tissue was remarkably pale, and readily broke down
into a pulp under the finger. The gall-bladder was filled with a liquid like
turbid water. The cystic duct was free. The hepatic and common ducts
contained a citron- coloured fluid, which reminded one of urine. The open-
ing of the common duct into the duodenum, was free.
The spleen was large and soft.
On the posterior surface of the stomach was an ulcer, the size of a crown-
piece, whose bottom was formed by the pancreas, which was healthy and
united to the rim of the ulcer by firm and close areolar tissue. The edge of
the ulcer was smooth and round. The mucous membrane about it white,
and not thickened or soft. In the splenic extremity of the stomach, the
mucous membrane was of a bright red. There was no mark of disease in
the duodenum, or the rest of the intestine, except that the follicles in the
colon were remarkably developed. The large intestine contained solid faecal
matter, of greyish- white colour.
In this case, as in the former, there was great softening of the
liver, — which was pale and not much enlarged, — with very scanty
secretion of bile. The case, however, is not so distinct in character
as the former, on account of the presence of an ulcer in the
stomach, which was evidently of old date, and to which the symp-
toms were, without doubt, in some measure owing.
In all the cases that have been related in this chapter, the con-
dition of the liver differed from that which results from perma-
nent closure of the common duct, in respect of its colour, and its
much greater softness and frangibility. In closure of the common
duct, the cells are broken down and disappear, hut the other ele-
ments of texture remain firm, so that, although the organ may feel
flabby, it is not readily broken down or torn.
It appears from this, that great softness and frangibility of the
224
SUPPRESSED SECRETION OF BILE.
liver depends less on thestate of the cells than on that of the vascular
network and other tissues, and that it cannot he inferred from these
characters merely, that the cells are destroyed. The liver may he
extremely soft and frangible, where the cells are entire and the
secretion of bile is performed as usual.
In a woman, who died under my care in Kang’s College Hos-
pital, in June, 1844, of tubercular peritonitis, all the upper part
of the liver, thirty hours after death, when the body was examined,
could be torn by the slightest effort, like a piece of rotten sponge.
The portions near the lower edge were very much firmer. The
liver was very large, and, throughout, of a yellowish-green colour.
The hepatic cells were gorged to bursting with oil- globules, and a
small piece of the liver burnt with a blaze when placed to the
flame of a candle. There was no jaundice, and the only symp-
tom that the liver was diseased was its large size.
Andral (Clin. Med. iv. p. 320) has given the case of a man who
died of phthisis, without jaundice or other symptom of disease of
the liver. The liver, which was rather large, was singularly
softened — so that in many points it was a mere pulp.
These cases strengthen the inference, that, in the cases in which,
with similar softening of the liver, the secretion of bile was
suppressed, the hepatic cells were destroyed or damaged.
I have brought together from different sources the cases related
in this chapter, for the sake of showing that the secretion of bile
may be suppressed, and the secreting substance of the liver be more
or less disorganised, in various circumstances, and without the occur-
rence of any process that we are warranted in designating, inflam-
mation. It would seem that this suspension of the secreting process
and disorganisation of the liver, may result from powerful and de-
pressing emotions ; but that it is far more frequently produced by
some poison, introduced from without, or generated in the body
by faulty assimilation or digestion. It appears, too, that various
poisons, — pus, the poison of serpents, perhaps the poison of some
forms of fever, and various others, — may alike stop the secretion
of the liver, and lead to the same kind of disorganisation of its
structure, while their other effects on the system are very different.
It is probable, too, that in some cases, as in those last related, the
disorganisation is produced slowly and gradually, and so without
shock; while in the more terrible forms of disease, of which
DIAGNOSIS.
225
instances were before given, the disorganisation is sudden and
rapid. These circumstances serve to explain the different charac-
ters of the illness that attended the suppression of bile in the
different cases related. They were many of them cases of essen-
tially different diseases, and having merely this one effect, and
the consequences of this effect, in common.
It does not seem possible to deduce from the cases that have
been related, any sure means of distinguishing jaundice that
results from suppressed secretion, from jaundice produced by
temporary closure of the ducts, except in the particular cases
where the jaundice immediately follows a powerful emotion, oi
occurs in the course of purulent phlebitis, or in consequence of
some known poisoning; or where, as in the instances related by
Dr. Griffin and Dr. Hanlon, it occurs with peculiar characters in
several members of a family, or in several persons living together,
in succession. In all these instances, knowledge of the cause of
the disease, or of some peculiar circumstances under which it may
have arisen, gives significance to symptoms that would otherwise
be vague and ambiguous. In other instances, where we have no in-
sight of this kind, and where the cause of the disease is unknown
to us, where, consequently, our judgment must he formed from
the symptoms merely, the diagnosis is much more difficult. But
even here we are not entirely without guides. An important
circumstance is that in the form of disease considered in this
chapter, the liver is almost always diminished in size ; while in
most of the other diseases in which jaundice occurs, the liver
is generally enlarged. Other circumstances, which it is im-
portant to bear in mind, are, that in most of the cases related
in this chapter there was vomiting; and also, that in most of
them, the flow of bile into the duodenum was not completely
stopped, as it often is, when jaundice results from obstruction
in the ducts. The matters brought up by vomiting, and passed
by stool, were coloured by bile. When delirium, or coma, or
convulsions, supervene, we may be almost sure that the jaundice
results from suppressed secretion ; because these symptoms
seldom occur in jaundice that results from mere obstruction of the
ducts.
Until more is known of the causes of this form of disease, and
until it can be detected with more certainty, we cannot expect to
Q
226
SUPPRESSED SECRETION OF BILE.
have satisfactory proofs of the good or ill effects of particular
plans of treatment. The conclusion that may he most safely
drawn from the foregoing cases, is, that in some instances, coma
may probably be prevented or removed, and the life of the patient
saved, by active purging.
227
Sect. II. — Fatty degeneration of the liver — Partial deposit of
fat in the liver — Waxy liver — Appearances caused by defi-
ciency of fat in the liver.
It lias been before remarked that the size, and colour, and
firmness, ofthelivei’, may become much altered, without the agency
of inflammation, and without any destruction of the cells or impaired
nutrition of its other tissues — simply from matter being secreted
or appropriated by the cells, which, instead of passing off freely in
the bile, is retained in the substance of the liver.
The most common disease of this class is, what has been called
the fatty liver, or fatty degeneration of the liver .
The outward characters of this disease have been long familiar to
pathologists, and have been rightly ascribed to the interstitial
deposit of uncomhined fatty matter in the substance of the liver ;
but it was not known precisely in what state, or where, the fat was
deposited till 1841,* when Mr. Bowman discovered, in a specimen
of very fatty liver which I requested him to examine with this
intent, that it existed in the form of oil-glohules in the hepatic
cells.
In every human liver, there is some uncombined oil or fat,
which is usually, however, in very small quantity. It may be
extracted from the liver by boiling, and may be seen through the
microscope in the hepatic cells, in the form of very small globules,
having a dark outline. These globules are of various sizes, and
are placed irregularly in the cells. Their usual appearance is re-
presented in fig 6, (p. 1 I .)
In the fatty liver, the quantity of oil so placed is enormously
increased. The hepatic cells are gorged with large globules,
Q 2
* See Lancet, Jan. 22nd, 1842.
228
FATTY DEGENERATION OF THE LIVER.
which greatly distend them, and often obscure their nuclei. This
is represented in fig. 8, (p. 14.)
Usually a great number of oil globules of various sizes, not
contained in cells, are likewise seen under the microscope.
The quantity of oil thus accumulated in a liver may equal in
weight, and more than equal in bulk, all the other elements of
the liver put together. M. Vauquelin obtained from a portion
of fatty liver, by boiling, as much as 45 parts of oil in 100
of liver. Nearly half the liver, in weight, consisted of uncombined
oil.
A liver that has undergone the fatty degeneration, may be little
altered in shape, but it is larger, and paler, and softer, and more
greasy, than natural. These changes in its sensible qualities
depend chiefly, if not solely, on the interstitial deposit of the
oil-globules, and their degree may give us some estimate of
the quantity of oil the liver contains. When this is very large,
the liver is large in proportion, sometimes twice its natural size,
and is generally somewhat altered in shape, being thicker than
natural, and having its edges blunter or more rounded. The capsule
of the liver is stretched and smooth, and when divided its edges
recede. The tissue of the liver is pale, and, generally, throughout
of a soft huff colour, dotted with brown or red. The brown or
red dots mark the centres of the lobules, which are unusually
large and distinct, and are buff-coloured near their margins. The
liver is very soft, and greases the hands, or the scalpel, like com-
mon fat.
When the quantity of oil is less, the liver is not so large, nor so
pale, nor so soft, — but presents an appearance described as the
nutmeg-liver. The liver may not feel greasy, but an unusual
quantity of fat may be at once detected by placing a thin slice
of the liver on a piece of paper, and exposing it to the action of
heat. Some of the oil or fat exudes, and greases the paper. The
best way, however, of ascertaining the quantity of fat — at least
that which exists in the form of oil-globules— is by examining a
small particle of the liver through the microscope. The oil-
globules are objects of sight, and from their form and their dark
outline, are at once distinguished.
Few observations have been made on the bile secreted by a
CAUSES.
229
fatty liver. It is sometimes unusually pale, and, it is said,
less bitter than natural; (Andral, Clin. Med. iv., p. 212;
and Meckel Anatomie, t. iii. p. 470 ;) but it has generally the
greenish or olive colour proper to bile. Not unfrequently, indeed,
in persons dead of phthisis, with fatty liver, (which is very apt to
occur in this disease,) the bile is unusually dark- coloured and
thick ;* but this is probably owing to its having remained long
in the gall bladder and become concentrated, in consequence ol
the repugnance to food, and the empty state of the stomach and
intestines, so common in the advanced stage of phthisis.
An accumulation of fat in the hepatic cells, notwithstanding it
so changes the appearance and other sensible qualities of the
liver, seems not to interfere much with its office. There is no
jaundice; no congestion of the veins that feed the vena port®, —
no obstruction, therefore, to the circulation through the liver ; no
pain, or even tendeimess. The only inconvenience the patient suffers
from this condition of the liver, is that which arises from the bulk
of the organ, — distension of the belly, and a sense of fullness and
weight, on turning in bed from the right side to the left. The
reason of there being no jaundice is, that the colouring matter of
the bile is secreted, and passes off, as usual. The absence of other
symptoms seems to depend on the softness of the oil-globules, and
the readiness with which they change their form and yield to
pressure ; on their being deposited gradually and evenly, so as
not to cause sudden stretching of the capsule of the liver ; and on
their having no tendency to excite inflammation of the capsule, or
of the veins.
The liver becomes fatty in very different states of the body.
1st. — It is often fatty in persons who lead indolent lives, and
are at the same time gross feeders — eating largely of fatty sub-
stances, and drinking freely of spirits, but more especially of porter
and other heavy malt liquors ; and is then generally associated
with excess of fat under the skin, and in other parts of the body
in which fat is usually deposited.
The fattening effect of food depends much on climate, but
in man, still more on individual peculiarities of constitution.
Some persons can take no fatty substances, without being dis-
ordered by them ; others take them with apparent impunity, but
* See Louis, Itecherches sur la Phthisie, 2ieme edition, p. 122.
230
FATTY DEGENERATION OF THE LIVER.
still remain lean — the fat is not digested, or not assimilated ;
others, again, take them freely, and grow fat in consequence.*
In our domestic animals, the fattening influence of fatty sub-
stances taken as food, is far more constant. It was well exhi-
bited in the experiments, lately performed by Majendie, for the
purpose of ascertaining the nutritive powers of different kinds of
food. In one of these experiments, a dog was kept entirely on
fresh butter, which it continued to eat, though not regularly, for
sixty-eight days. “ It then died of inanition, although re-
markably fat. All the while the experiment lasted, the animal
smelt strongly of butyric acid, its hair was greasy, and its skin
covered with a layer of fat. On dissection, all the organs and
tissues were found infiltered with fat. The liver, to use the com-
mon phrase, was fatty ; and, on analysis, it was found to contain
a very large quantity of stearine, hut little or no oleine. It had
acted as a land ofjilterfor the hatter I
Many other experiments of the same kind were made with
bog’s-lard, and other fatty substances, and with a like result.
The dogs became loaded with fat, but their muscles wasted, and,
at length, they died of inanition. In many of them, the cornea
sloughed. In all, the liver was fatty.
These experiments are interesting, from showing clearly that an
animal may be loaded with fat, and yet die of inanition. They
place in a strong light, the truth of the observation long ago made
by practical physicians, that fat people are not so strong as they
look, and, in general, ill bear losses of blood or other lowering
measures. The muscles of fat people are small, and it is muscle
that gives strength.
Greasiness of the skin and the smell of butyric acid, which
were remarked by Majendie in his dogs, have also been noticed
in men, who, from gross feeding and indolent lives, have their
livers and other tissues loaded with fat. Rokitansky says, the
fatty condition of the liver in these men, is attended with sallow-
ness of the skin, and with a greasy sweat of peculiar odour.
The fatty matter passes of by the skin, as well as by the liver,
* Prout, Stomach and Urinary Diseases, 3rd edition, p. 242. Some im-
portant remarks on these points, and valuable hints for future inquirers, will
be found, in the chapter here referred to, in Dr. Prout’s profound work ; to
which we are so deeply indebted for our knowledge of the various effects of
faulty digestion and assimilation.
CAUSES.
231
and in precisely the same way — through the nucleated cells of
the sebaceous glands. In a state of health, the cells of the seba-
ceous glands, like those of the lobules of the liver, contain small
globules of oil. There can be no doubt that where the body is
loaded with fat, the quantity of oil in the former cells, as well as in
the latter, is enormously increased. This observation is important,
because it gives optical proof, that some of the matters eliminated
by the liver, may also be eliminated through the skin, and be-
cause it tends to impress on us the importance of attending to the
skin in all cases in which the functions of the liver are deranged.
In the cases under consideration, it is clear, that the liver is
not primarily in fault, any more than the skin. Both of them are
fulfilling their proper office, in getting rid of an excess of fatty
matter in the blood.
2nd. — But the liver is often found fatty in persons dead of
phthisis, who, instead of being loaded with fat, are generally much
wasted.
The frequency with which the liver undergoes this change in
phthisis was, I believe, first pointed out by M. Louis, in his cele-
brated work on phthisis, published in 1825. M. Louis detected
the fatty degeneration by the altered look and feel of the liver, in
forty cases of phthisis, out of 120, — or, in one-third of the sub-
jects he examined.
It appears from his researches, that this change in the liver, in
pulmonary consumption, is irrespective of age, and equally fre-
quent, whether the consumption be rapid or lingering. The only
condition which he ascertained to have a marked relation to its
frequency, is sex. It was nearly four times as frequent in the
women he examined, as in the men. In the cases he has since
observed, the proportion of women to men is still larger. In
the second edition of his work, published last year, (1843,) he
states that in fifty-four fatal cases of phthisis, which he has
observed at La Charite, since the publication of the first edition,
the liver was fatty thirteen times, and only in women, who were
thirty in number.
These results have been confirmed by observations made in
other countries.
Dr. Home, out of sixty-five persons who died of phthisis in the
Edinburgh Infirmary, found the liver fatty in ten, and waxy in
232
FATTY DEGENERATION OF THE LIVER.
five others. These fifteen instances, with one exception, occurred
in women.*
In twenty-three of these sixty-five cases, the liver presented
different forms of the early stage of cirrhosis. This condition i3
not noticed by Louis in his account of the morbid appearances in
phthisis. It is, no doubt, more common in Edinburgh than in
Paris, in consequence of the habit of whiskey-drinking among
the lower classes in Scotland. But it is probable that in some of
the cases, Dr. Home mistook the nutmeg appearance of the liver
caused by the deposit of fat in moderate quantity, for the early
stage of cirrhosis. Making a trifling allowance for an error of
this kind, it would appear that fatty degeneration of the fiver
is just as frequent, in persons dead of phthisis, in Edinburgh, as in
Paris.
I know of no other evidence by which we can judge of its rela-
tive frequency in different places, except a remark by Dr. Stokes,
that he thinks it less frequent in Dublin than in Paris.
Fatty degeneration of the fiver in such degree as to he at once
recognised, is not only frequent in phthisis, but, — setting aside
the persons in whom the fiver is loaded witfi fat in common with
ihe areolar tissue and other parts of the body in wdiich fat is
liable to he deposited, — is almost peculiar to this disease. Fre-
quently, indeed, in subjects dead of various diseases, an unusual
quantity of fat is found in the liver, which is at once discovered
by the microscope, and which may be detected by a practised eye,
by merely looking at the fiver, — but tfie fatty degeneration is
seldom so advanced as to be readily recognised at sight, except in
persons dead of phthisis. M. Louis states, that in the course of
three years he met with forty-nine instances of fatty fiver, and in
forty-seven of tliese, the patients were phthisical.
In speculating on the cause of this peculiar tendency to accu-
mulation of fat in the fiver, in phthisis, it is important to remark,
that it does not depend on tuberculous disease of the fiver itself.
M. Louis states, that there were no tubercles in the liver in any
of the cases in which he found it fatty : and that in two cases in
which there were tubercles in the fiver, tfie liver was not fatty,
lie even infers, that the one state may preclude the other, and
cites in support of this opinion, a remark made by M. Reynaud,
* Lib. of Med. iv. 163.
CAUSES.
233
in his essay on phthisis in monkeys — that although, in the mon-
keys he dissected, the liver very frequently contained tubercles, it
was in no instance fatty. My own observations tend, in some
degree, to confirm this remark. The natives of the South Sea
Islands, who come to this country, are here extremely liable to
phthisis, like the monkeys brought to Paris and London, and to
the deposit of tubercles in various organs besides the lungs. 1
have found the liver and various organs studded with tubercles in
several of these men who died in the Dreadnought of phthisis,
but in none of these instances did I remark that the liver was
fatty.
It has been imagined, that fatty matter accumulates in the
liver in phthisis, in consequence merely of the office of the lungs
being greatly and gradually interfered with — that hydro-carbon-
aceous matters, passing off in less quantity than natural through
the lungs, are, in consequence, eliminated in larger quantity by the
liver. This opinion is rendered very improbable by the circum-
stance, that in organic diseases of the heart, and in asthma,
where the office of the lungs is not unfrequently as much inter-
fered with as in phthisis, the liver does not become fatty. Still
stronger refutation of it is afforded by tlie fact, noticed by Ro-
kitansky, that fatty degeneration of the liver is found in conjunc-
tion with tuberculous disease of other organs — the mesentery, the
serous membranes, the bones — when there are no tubercles in the
lungs.
These facts show that we must seek the explanation of the
fatty degeneration of the liver in phthisis, in some other condi-
tions than mere diminished function of the lungs.
It has been already remarked that the fatty condition of the
liver, independent of excess of fat in other organs, is very seldom
met with, at least in such degree that it can be at once recognised,
except in persons dead of phthisis. Now and then, however, the
liver is just as fatty after other diseases, and we may naturally
expect to find the conditions on which the accumulation of fat in
the liver really depends, in some points of resemblance which
these exceptional cases bear to cases of phthisis. These excep-
tional cases demand then great attention in our present inquiry.
The most fatty liver that has fallen under my own observation
for several years, was that of a man, who died in King’s College
234
FATTY DEGENERATION OF THE LIVER.
Hospital, last April, (1844,) at tlie age of 36, of extensive can-
cerous ulceration of the groins.
He was a chimney-sweep, and had good health till about nine
years before, when he noticed a pimple on the left side of the
scrotum, which gradually grew larger. The pimple was cut out,
and the wound healed. He then gave up chimney- sweeping, and
became a coal-porter, and from this time enjoyed good health till
February 1843, when another pimple, like that which had been
cut out, appeared on the opposite side of the scrotum. He was
admitted into St. Bartholomew’s Hospital, where this tumor also
was removed. The wound healed, as after the former operation.
About a month after this, the glands in the right groin enlarged
and became painful, and shortly afterwards suppurated and hurst,
leaving a ragged deep ulcer in the course of Poupart’s ligament.
A similar swelling soon appeared in the left groin, and burst,
leaving a similar ulcer, but less extensive. In this state he was
admitted into King’s College Hospital, under Mr. Partridge, on
the 14th of Sept. 1843. He was then much emaciated, and his
liver was felt to be somewhat enlarged. His complexion was
somewhat dusky, hut not sallow. Pie had no cough or difficulty
of breathing. His appetite was very good, and he was free from
thirst. He wras ordered full diet, with a pint of porter ; and a
watery solution of opium was applied to the ulcers. The ulcers
gradually spread till they were of frightful extent, hut even then
his appetite continued tolerably good. Pie gradually sank, and
died on the 8th of April. Sweating is not mentioned in the
notes that were taken of his case.
The liver was very large, and very thick, and, throughout, of a
pale buff colour, from extreme fatty degeneration. It greased the
scalpel, and under the microscope, the hepatic cells were found
gorged wdth oil-globules. The bile also contained a great number
of oil-globules, visible under the microscope, together with dis-
tinct particles of greenish colouring matter. The capsule of the
liver presented no trace of inflammation. Except this change in
the liver, there was no disease, but the frightful ulceration of the
groins. There were no cancerous tumors in any of the viscera.
The lungs were congested, but, otherwise, perfectly healthy.
A case, in some respects similar, is recorded by Cruveilhier, in
which a high degree of fatty degeneration was found in conjunc-
CAUSES.
235
tion with disseminated melanotic cancer, and with a large psoas
abscess, that resulted from caries of the lumbar vertebrae.
The patient, a woman 30 years of age, was brought into the Hotel Dieu, in
a state of extreme exhaustion, and died the next day.
Cruveilhier has given a plate representing the front of the body, which was
thickly studded with melanotic tubercles in, or under, the skin. There were,
also, a great number of grey melanotic tumors in the lungs, and in the me-
sentery; many adhering to the kidney, and in the areolar tissue about it;
many along the iliac and hypogastric arteries and veins. There was, like-
wise, an enormous medullary tumor, growing from the sacrum, which filled
the cavity of the true pelvis, but all the organs of the pelvis were sound. In
the upper, or expanded portion of the pelvic cavity, there was a very large
abscess, under the iliac fascia. The matter of this abscess came from the last
lumbar vertebra, which were carious. It extended in the sheath of the psoas
muscle as low as the little trochanter. The liver was yellow, and had under-
gone complete fatty degeneration, ( avait passe completement au gras,) but
contained no cancerous tumors. (Liv. xxxii. pi. 3.)
This case presents many striking points of resemblance with
the cases of phthisis, in which the liver is fatty. The patient was
a woman, much emaciated. From this last circumstance, and
from the wide dissemination of cancerous tumors, it may safely be
inferred, that she was in a state of cancerous cachexy, and proba-
bly subject to the profuse sweating common in this state. Lastly,
the liver was completely fatty, but, what is very unusual when
cancer is so widely disseminated, contained no cancerous tumors.
In the following case, which I have copied from Dr. Bright’s
Hospital Reports, fatty degeneration of the liver was found in
conjunction with chronic dysentery, which had led to perforation
of the lower part of the large intestine, and the consequent forma-
tion of a large abscess behind it.
Case. — A. B., a young man about 28 years of age, originally stout,
vigorous, and active, who had been regular in his diet and very temperate in
the use of wine and other fermented drinks, but had frequently been the
subject of syphilis. Some few years before his death, he laboured under a
dysenteric affection, on the subsidence of which, his bowels became habi-
tually constipated. This state appeared to be in part attributable to a stric-
ture of the rectum, which was felt at no great distance from the anus : a
bougie was passed, and a considerable dilatation of the stricture was effected.
His health continually declined, and symptoms of stricture higher up in the
236
FATTY DEGENERATION OF THE LIVER.
intestine became evident. An abscess was formed just above the crista of
the ileum posteriorly, which, on its opening, proved to have communication
with the intestine. Pain was felt in the upper part of the left iliac region.
Leeches were applied, and their bites produced sinuous ulcers. He had no
cough, or obvious chest affection ; latterly, he had some diarrhoea, and wasted
rapidly.
The head was not opened. There was some old pleuritic adhesion on the
left side, but none on the right. The lungs and heart were quite healthy.
In the left iliac region the intestines were glued together by peritoneal adhe-
sions, and firmly bound down on the iliacus internus muscle. The cellular
membrane below the peritoneum was very firm and much thickened. The
mucous membrane of the stomach was free from rugae, rather firm, and not
easily separated from the subjacent coat ; towards the cardia it was of a
diffused dusky livid colour : that of the duodenum was pale, but its mucous
glands were enlarged : that of the rest of the small intestines was tolerably
healthy. The same was the case with the first part of the large intestines ;
hut in the sigmoid flexure of the colon, and more particularly in the lower
part of it, there were numerous traces of old ulcerations : these were of a
lightish leaden colour, of an uneven surface; and the structure of the intes-
tine at this part was thickened and condensed, and its calibre greatly con-
tracted : there were three or four small perforations through the intestine at
this part. Inside the last part of the colon and the whole of the rectum
appeared healthy ; but a little above the anus there was a decided thicken-
ing with induration. This evidently depended on an old ulcer, which had
occupied about half-an-inch of the intestine. Like those of the colon
it exhibited a leaden hue, an uneven surface, an apparent deficiency of the
mucous coat and thickening of the subjacent structure. The liver was re-
markably enlarged, and of a yellowish-brown colour; it was veiy exsan-
guine, and had universally undergone the fatty degeneration. It felt soft
and plastic under the fingers, soiled the clean blade of a scalpel which was
thrust into it, and yielded an oily fluid on the application of heat. The
gall-bladder was small and contracted, and Contained no bile but a little
dirty-coloured somewhat puriform mucus. The patient, however, had some
bilious vomiting but a few days before his death. The spleen was of mode-
rate size and firm, and the kidneys were healthy. (Bright’s Reports, vol.
i- P-117)
In the spring of the present year, Mr. Busk sent me a portion
of liver extremely fatty, taken from a lad, set. 17, who died of
chronic dysentery. The lad was much emaciated, hut had no
disease of the lung other than recent bronchitis. He died a few
days after he was brought to the Hospital, and while under treat-
ment, there, had no sweating.
In the autumn of last year, I found a very fatty liver in a
woman, who died under my care in King’s College Hospital, of
CAUSES.
237
grey hepatisation of the left lung. Her illness lasted a month.
Towards the end, she had much hectic and sweating. There were
no tubercles.
It is stated hy MM. Biett and Rayer, that a fatty condition of
the liver is very common in persons with chronic pemphigus —
persons almost invariably very low in condition.
It would seem, from these instances, that the fatty condition of
the liver so common in phthisis, does not result from the office
of the lung being interfered with, or from the presence of tu-
berculous matter in any particular organ, hut rather that it is
connected in some way with the general constitutional disturbance
— the abundant suppuration, the wasting, the hectic, — so common
in advanced stages of phthisis.
The opinion was some years ago advanced by the late Baron
Larrey, that the fatty condition of the liver in these cases results
from solution of the fat previously laid up in the body. He con-
sidered this opinion strongly supported by the method then em-
ployed in France to make the livers of geese fatty, and of which he
gives the following account : “ To procure the large livers of
geese, for the making of patties, fatted birds are confined in close
cages, and then exposed to a graduated heat, being kept at the
same time entirely without food, even without water. They be-
come feverish, the fat undergoes a kind of fusion, and the liver
grows enormously large. The liver is considered to he in the
desired state, when the animal is extremely wasted, and the fever
increases,”
It is quite clear, that, in this process, the fat which accumulates
in the liver, is derived from that previously laid up in the body.
It is extremely probable, that the same tiling happens in phthisis,
and in the other wasting diseases in which fatty degeneration of
the liver occurs, in man : — that, in the process of wasting, the fat
stored up in the body is largely taken up hy the veins, so that it
comes to be in excess in the blood, and is then laid hold of hy the
hepatic cells, which have a natural affinity for it. Fat is, without
doubt, secreted in large quantity by the liver, and hy the sebaceous
glands, whenever a large quantity of it finds its way into the blood.
If this opinion he correct, it follows, that in this class of cases,
as in those before spoken of, the fatty condition of the liver cannot
he considered essentially a disease of the liver, any more than
238
FATTY DEGENERATION OF THE LIVER.
diabetes can be considered a disease of the kidneys. In certain
states of the system, the liver eliminates an unusual quantity of
fat, just as in certain other states the kidneys eliminate sugar.
The fat in the liver, being in the form of large oil-globules, -which
are perhaps only slowly dissolved in the bile, is long pent up in
the close meshes of the capillary network of the liver, and, of
course, adds to the size of the liver, and alters its texture, — while
sugar, from its solubility, and from the large quantity of water
secreted with it, is at once carried out of the system, and leaves
the kidneys unaltered.
In both diseases, the other principles which it is the office of the
organ that is seemingly in fault to excrete, are excreted as usual.
Dr. Christison has said that in saccharine diabetes, urea, uric acid,
and the other constituents of urine, are often secreted nearly in the
same quantity, and in the same relative proportions, as in health ;
and that the urine may be considered healthy urine, with the addi-
tion of so much sugar.
If we may judge from the clearness of the complexion in phthisis,
and from the colour of the bile found in the gall-bladder, which is
often dark-green or olive, when the liver is fatty, the ordinary con-
stituents of bile in this disease pass off as usual. The liver seems
not to be at fault, but to be merely performing its allotted task, in
withdrawing an excess of fatty matter from the blood. The ques-
tion then comes to be, why is the fat taken up by the blood in
such quantity in phthisis as to be present in great excess in that
fluid? If it be to serve as fuel for respiration, why is not the
liver fatty in all chronic diseases, which prove fatal by slow ema-
ciation ? Why does the liver become fatty so much more fre-
quently in women affected with phthisis, than in men ? As yet no
satisfactory answers have been given to these questions. *
But although in the class of cases already considered, the liver
may not be primarily in fault, it is probable that fat may also
accumulate in the liver, as in other organs, from local causes,
— causes affecting, directly, the nutrition of the part. When the
degeneration depends, not on fault of the liver, but solely on con-
stitutional causes, the whole organ must be affected alike — and
* The greater frequency of fatty liver in women may be partly accounted
for by the circumstance that women are, in general, fatter than men.
CAUSES.
239
this is always the case in the fatty liver of phthisis. Butit now
and then happens, that a very small portion of the liver, the size,
it may he, of a walnut, is completely fatty, while the rest of the
organ is quite sound. During the last year, I have met with three
instances of this. One was in a portion of liver sent me by Mr.
Busk, taken from a man who died in the Dreadnought, with enor-
mous cavities in the lungs, which were probably tuberculous. The
only morbid appearance on the surface of the portion of liver sent
me, was a pale drab-coloured spot, the size of a shilling. When
this was sliced across, a portion of the liver immediately beneath,
as large as a walnut, with an irregular outline, was found to be of the
same pale colour, contrasting strongly with the colour of the rest
of the liver, and completely fatty. The appearance of this portion
was precisely like that of extreme fatty liver in phthisis ; and,
under the microscope, the hepatic cells were seen to be filled to
bursting with oil, while the cells in the rest of the liver had scarcely
more oil than natural. There was another spot in the same state,
and about the same size, in a different part of the liver.
The second instance was in the liver of a woman, who died, in
King’s College Hospital, of diseased heart. She was reported to
have drunk freely of spirits. At the surface of the left lobe near
the suspensory ligament, was an irregular portion, the size of a
small walnut, soft, and of a pale yellow colour, in strong contrast
with the colour of the other portions. The cells in this pale por-
tion were gorged with oil-globules ; in the rest of the liver, they
were healthy- In another portion of the left lobe there was some
atrophy, and the surface was slightly puckered, from obliterated
branches of the portal vein.
The third instance was in a girl, aged 20, who died also in
King’s College Hospital, of chorea. The capsule of the liver was
united to the diaphragm and the abdominal parietes by threads of
old false membrane. On the surface of the liver were two or
three pale spots, like those before described, of about the same size,
and having the same irregular outline. Under the microscope,
the hepatic tissue forming these spots, exhibited a few cells, gorged
with oil-globules, and an immense number of free oil-globules.
Throughout, the liver contained more oil than natural. In these
two last cases, there was no tuberculous disease of the lung. From
the fat being deposited so partially, and from the presence of marks
of former inflammation of the liver, we arc perhaps justified in in-
240
FATTY DEGENERATION OF THE LIVER.
ferring that the complete fatty degeneration resulted, here, not so
much from general, or constitutional causes, as from some local
cause affecting the nutrition of those parts.
In a case of scrofulous enlargement of the liver, of which the
details will be given further on, fat was also deposited partially in
the liver, but in a different way. Instead of forming large isolated
spots, it was chiefly in white lines, along the small twigs of the
portal and hepatic veins. On the surface of the liver, there were
some lobules completely fatty, hut along the vessels, the fat did not
seem to he in the lobules.
In other parts of the body, in persons even much emaciated,
accumulations of fat are often found in wasted parts, especially
where a certain form must he preserved for the due exercise of
their functions. This is especially the case with the heart.* Fat
is almost always found about the heart, in persons above the age
of infancy, gradually increasing in quantity, as the two sides of
the heart become more unequal in hulk. This fat, as Mr. Paget
has shown, serves a mechanical purpose, and allows the different
cavities to assume readily the changes of volume and position,
which the entrance of the blood, and its forcible expulsion, re-
quire. In phthisis, where the muscles of the heart, like other
muscles, waste, and where the fat of most parts of the body dis-
appears, an unusual quantity of fat is sometimes deposited about
the heart ; f in obedience, it would seem, to the law, which de-
termines the deposit of fat about the heart in health, as, by the
progress of age, the inequality of the two sides of the heart
increases.
Accumulation of fat about the heart, in phthisis, is associated
with accumulation of it in the liver. Like the latter, it is
almost exclusively met with in women, and is seldom found
in persons dead of other wasting diseases. In phthisis, as in
the process, before described, that was formerly employed to
make the livers of geese fatty, the fat previously laid up in
the body, seems to he absorbed by the vessels in greater quan-
tity than is requisite to combine with the oxygen inhaled.
* For an account of the manner in which fat is deposited about the heart,
see an elaborate paper by M. Bizot, in the first volume of “ Memoires de la
Soceite Medicale d’Observation.”
t For an account of the fatty state of the heart in phthisis, see “ Louis sur
la Phthisie.” Second Edition, p. Gl and 63.
CAUSES.
2J1
The excess of fatty matter thus present in the blood, is, in part,
eliminated by the glands destined to excrete fat ; in part, deposited
about the heart, where, from the wasting of other tissues, an addi-
tional quantity of it seems to be required to serve an important
mechanical purpose, and where, by the wisdom of creation, forces
have been placed which strongly favour its accumulation to the ex-
tent requisite for that purpose. The difficulty that before presented
itself, meets us again here. Why does the fat laid up in the body
become absorbed, so as to be in excess in the blood, in phthisis, and
not, also, in other chronic diseases equally wasting ?
The bones of persons very advanced in life, always contain a
large quantity of oil, which accumulates in them as the vascular
part of their structure shrinks, — it would seem, for no other end
than to occupy space.
Another situation in which fat accumulates, and apparently
for the same end, — to occupy space, — is under the integument
of the belly in women who have had many children. In a
woman who died in King’s College Hospital, in the autumn of
1842, of stricture of the pylorus, although the body generally
was extremely emaciated, there was a layer of fat, an inch thick,
on the abdominal muscles. Andral, from the observation of simi-
lar facts, was led to imagine, that the fatty state of the liver in
phthisis might result from atrophy of its proper tissues. (Clin.
Med. iv. p. 174). There is, at present, no evidence to support
this opinion.* The liver becomes fatty without any previous
diminution of size, and tbe accumulation of fat, so far from being
intended merely to fill up a void, may go on till the natural
volume of the liver is doubled.
It is probable, however, that in some of the cases in which fat
is found in less quantity, or in parts only of the liver, the fat may
merely take the place of other tissues.
But occasionally fat is deposited in great quantity in particular
parts, from causes that affect their nutrition, without previous
wasting of their proper structure, and where no beneficial mechanical
purpose seems to be answered by it. This frequently happens in the
neighbourhood of cancer. Cancerous tumours of the breast, and
* This opinion is likewise advanced by Dr. Thompson, in an excellent
article on Diseases of the Liver, published in the Library of Medicine. (Lib.
of Med. vol. iv. p. 190.)
R
242
FATTY DEGENERATION OF THE LIVER.
cancerous glands in the axilla, are often surrounded by a large quan-
tity of fat. The frequent accumulation of fat about cancer has been
particularly noticed by Cruveilhier, who has given a striking in-
stance of it, in a case of colloid cancer of the stomach, with can-
cerous tubercles in the mesentery. (Liv. 27, PI. 3, p. 1.)
In examining the bodies of sailors, who have died much reduced
by chronic dysentery, I have been often much struck with the
large quantity of fat in the appendices epiploicce, and elsewhere in
the neighbourhood of the diseased intestine. In the dissections
of persons dead of chronic dysentery, related by Annesley, in his
work on the diseases of India, a fatty condition of the omentum is
also frequently noticed.
An unusual quantity of fat is sometimes found about a diseased
joint — but this perhaps results, in part, from wasting of the adja-
cent muscles.
This partial accumulation of fat about other disease, happens,
also, in the liver, especially in cancer. The hepatic tissue just
round a cancerous tumor has often a nutmeg appearance, from
containing an unusual quantity of fat, and not unfrequently is
for a short distance completely fatty. The substance of a can-
cerous tumor in the liver, as in other parts, occasionally, I be-
lieve, contains fatty matter.
In all the cases in which I have yet ascribed fatty degeneration
of the liver to local causes affecting the nutrition of the part, the
accumulation of fat has been partial. It may be, however, that the
entire organ may be damaged by some acute disease, or in other
ways, and may become fatty in consequence. I strongly suspect that
this happens in yellow fever, and in the severe bilious remittents
of tropical climates. These fevers, without leaving any permanent
marks of inflammation, and apparently without exciting inflam-
mation at all, may permanently alter the condition of the liver.
It often happens that the office of the liver is not adequately per-
formed for the future, and that years after, when the person dies,
perhaps from some disease quite independent of this, the liver is
found unusually pale. The pale colour of the liver depends, I
imagine, on fat — which is not, however, in such quantity as to
increase the size of the liver and to cause the striking appearances
of the extreme fatty liver in phthisis. It is not unlikely that long
courses of mercury, and other medicines that directly affect the nu-
trition of the liver, may, now and then, have a similar result.
WAXY LIVER.
243
Hitherto, we have considered merely tlie ordinary form of fatty
liver. But, now and then, what seems to be a modification of
it, is met with, which has been described by writers as the “ waxy”
liver. The liver is large and thickened, and the lobules are
large and distinct, as in fatty liver, but its texture is firmer and
closer than that of ordinary fatty liver, and it does not feel so
greasy. Often, it has a rich yellow colour, from the retention of
the colouring matter of bile. These characters are well expressed
by the epithet “ waxy, ” which has been applied to livers in this
state by Dr. Home and Rokitansky, and it would seem, quite inde-
pendently of each other. The term, indeed, expresses the appear-
ances so aptly, that it can hardly fail of being suggested to any
one describing this condition.
In the waxy liver, if indeed it be a mere variety of fatty liver,
the fatty matter must be firmer than in ordinary fatty liver, and
must contain a larger proportion of stearine. This state of the
liver was remarked by Laennec,* who considered it to be a variety of
fatty liver, caused by the deposit of the more solid forms of fatty
matter.
The relative proportion of stearine and oleine might be ascer-
tained by chemical analysis. It cannot be readily discovered by
the microscope, because the solid fats, although microscopic ob-
jects, and readily distinguished when separate, are soluble in
oleine, and consequently cannot be seen where there are many oil-
globules.
The “ waxy” liver, like the more common fatty liver, is met
with most frequently in women affected with phthisis. It is not
noticed by Louis in his accurate work on phthisis, probably from
his not having recognised its true nature.
In animals kept exclusively on fatty substances, and, perhaps,
in persons whose habits of life are such as to cause a fatty
fiver, the fatty matter may be deposited chiefly in the form of
stearine. In the dog that Majendie kept exclusively on fresh butter
for sixty-eight days, the fiver was found on analysis to contain a
large quantity of stearine, but little or no oleine.
Since fatty matter is deposited in the fiver in the forms of oleine
and stearine, it might be expected that it would also be deposited
in the chrystalline form, as cholesterine. But although masses of
cholesterine are often found in the gall-bladder, this substance
* Traite de L’Au.scullation, tom. ii. p. 3(5.
X 2
244
FATTY DEGENERATION OF THE LIVER.
being the chief constituent of gall-stones ; and although innumer-
able glistening scales of cholesterine are sometimes seen in the
cystic bile — 1 am not aware that an interstitial deposit of cho-
lesterine lias ever been observed in the substance of the liver, so
as to form a state corresponding to the fatty, and waxy , states,
that result from the deposit of other forms of fat.
In the specimens of fatty liver which I have examined, I have
never found a scale of cholesterine in the substance of the organ.
Cholesterine might, however, like stearine, be dissolved in oleine,
and might therefore be present in the substance of the liver without
being visible.
In the fatty degeneration of the gall-bladder considered in a
former chapter, cholesterine is generally secreted in very large
quantity by the diseased coats of the bladder.
Our knowledge of the frequency of fatty degeneration of the
liver in phthisis enables us often to discover it during the life of
the patient. In a woman labouring under phthisis, considerable
enlargement of the liver, without jaundice, or ascites, or much
pain or tenderness, is evidence enough, especially when the woman
has been of temperate habits, that the liver is fatty. But as this
condition of the liver causes but little inconvenience in itself, and
does not lead to inflammation, or to other secondary mischief, and
as the disease with which it is associated is inevitably fatal, it is
not an object of treatment.
When the liver becomes fatty from gross feeding and indolent
habits, the excess of fat will, doubtless, disappear from it, as from
other parts, on the person adopting an opposite mode of life. If
he will rise early, take active exercise, live chiefly on lean meat,
with plenty of salt, and drink water — and will abstain from butter,
bacon, oil, beer and other fermented drinks, and eat sparingly of
sugar* and potatoes — he will not only get rid of his fat, but his
muscles will be better nourished, and his strength be increased.
There are probably states of the system opposite to that we have
* Abstinence from sugar and its chemical equivalents is a point of great
importance. As sugar furnishes a material for respiration, which is soluble
in the blood, it is acted on by oxygen much more readily than the insoluble
fat, which is thus protected, and laid up in the system. Alcohol has a still
stronger protecting power, for similar reasons.
DEFICIENCY OF FAT IN THE LIVER.
245
just been considering, in which the fatty matter secreted by the
liver, instead of being in excess, is deficient. The disease in which,
more perhaps than in any other, we might expect to find deficiency
of fatty matter in the liver, is diabetes. In advanced stages of
diabetes, scarcely a particle of true fat can be found in the limbs,
in the cavity of the helly, or even about the heart. The brain,
too, is generally somewhat shrunk, probably from deficient
supply of fatty matter to repair its waste.* As excess of fatty
matter renders the liver large, and pale, and soft, and the indivi-
dual lobules large and distinct ; a deficiency of it must tend to
produce contrary effects. Where the cells contain but little oil,
and are small, or fewer in number than they should be, the lobules
of the liver are small and indistinct, and a cut surface of the liver
is smooth and uniformly red. The whole liver is of course
small, in proportion to the small size of the individual lobules.
These appearances have been cursorily noticed by several patho-
logists. Rokitansky has described them with his usual minute-
ness, under the term, red atrophy, which well enough expresses
the change. He says, “ In red atrophy, the liver is diminished
in size, wfith predominance of thickness ; it is of a dark brown, or
blood-red colour ; rich in hlood ; turgid, and has a peculiar
spongy, elastic feel. A cut surface presents a seeming homo-
geneity of structure, without appearance of lobules. The disease
has a chronic course, and is attended by plentiful formation of
tarry bile.”
* See Observations by Dr. Percy, of Birmingham, in the Medical Gazette,
April 7, 1843.
246
Sect. III. — Scrofulous enlargement of the liver , and other kin-
dred states.
A condition, analogous to the fatty liver, but differing from
it in the character of the matter deposited in the liver, is some-
times met with in persons much wasted hy scrofulous disease of the
glands or of the bones, and is spoken of by many writers as scro-
fulous enlargement of the liver. The following case of this kind
is related hy Portal.
Case. — A boy, 8 years of age, gradually wasted away. He bad distaste
for food of all kinds, especially animal food. The submaxillary glands were
enlarged, and on each side of the neck was a string of other enlarged glands.
The liver extended low in the belly. The child was in a slow fever, when
first seen by Portal, and died a fortnight after.
On dissection, the maxillary glands, the glands on each side of the neck,
and the bronchial and mesenteric glands were found enlarged, and filled with
a substance like plaster.
The liver was of prodigious size. When stripped of its capsule, the sub-
stance appeared whitish. In the interior, it was still whiter than on the
surface. On the surface, as well as in the interior, were lymphatic vessels
which contained a substance so thick that they formed small hard cylinders.
The matter with which the liver was gorged had the same whiteness. A
slice of the liver, exposed to heat, to the action of boiling water, or of alcohol,
was hardened, like albumen. (Mai. du Foie, p. 94.)
Portal concludes, that the disease is an albuminous obstruction
of the liver.
Another case of scrofulous enlargement of the liver is recorded
by Abercrombie.
Case. — “A boy, aged 11, in the winter 1811-12, was seized with great
enlargement of the glands under the jaw, his neck being completely beset
7
SCROFULOUS ENLARGEMENT OF THE LIVER.
247
with a chain of them of very large size, extending from ear to ear. He
improved considerably during the summer, but in the following winter he
became languid, and impaired in strength, with variable appetite, and irre-
gular attacks of fever. In the following summer, he was affected with cough
and dyspnoea, and it was now discovered that his liver was so much
enlarged, that the edge of it was distinctly felt as low as the umbilicus. He
had a wasted and withered look, with cough, frequent pulse, enlargement of
the abdomen, and anasarca of the legs ; the latter increased to a prodigious
degree, and he died after protracted suffering, in October, 1813.
Inspection. — The liver extended rather below the umbilicus, and so much
into the left side as to fill the upper half of the abdomen. It was a little
paler than natural in its colour, but in other respects was scarcely altered from
the healthy structure. There was extensive disease of the mesenteric
glands. The lungs were slightly tubercular, and there was a chain of en-
larged glands, some of them as large as walnuts, extending behind the lungs,
from the bifurcation of the tracluca to the diaphragm ; some of these were of
cartilaginous hardness, others contained thick purulent matter, and in others,
there were hard calcareous particles. There was considerable effusion in the
abdomen.”
(Abercrombie, Diseases of the Stomach, &c., 2nd ed. p. 366.)
The most detailed account of this condition of the liver is given
hy Rokitansky, who calls it the “ lardaceous ” liver. lie says,
“ Its anatomical characters are — considerable increase of volume,
with striking development in breadth and accompanying flatten-
ing ; very considerable gain in weight; a smooth, tight-stretched,
peritoneal coat ; a doughy consistence, combined with a certain
degree of resistance and elasticity ; anemia ; watery, pale-red
appearance of the portal blood ; greyisli-white or greyish-red,
(mingled with yellow or brown,) colour of the organ ; smooth,
homogeneous, lardaceous-looking section ; scarce any fat on the
knife-blade.” The morbid appearances, he adds, depend on in-
filtration of the liver with “ a compact, greyish, often transparent,
albuminous, lardaceous, or lardaceous-gelatinous substance.”
In the spring of 1 844, I had an opportunity of examining a
very striking specimen of scrofulous liver obtained from a boy
who was a patient of my brother, Dr. William Budd, of Bristol.
The boy had suffered many years from scrofulous disease of the hip, with
pieces of bone coming away through permanent fistulous openings. About
six months before his death, he became dropsical. There was general ana-
sarca, but dropsy of the belly predominated, and, on account of this, he was
tapped three times. After tapping, the ascites returned in an extraordinary
short time to the same degree as before. There never was any jaundice.
There was great emaciation at last, but it came on very slowly. There was
248
SCROFULOUS ENLARGEMENT OF THE LIVER.
very little fever, throughout ; and the appetite continued good up to a late
period. The boy had been always sickly, and, in consequence, was much
indulged by his parents ; — among other things, drinking, for a child, large
quantities of beer, of which he was very fond.
The liver was immensely enlarged, its edges were rounded, and its perito-
neal coat was remarkably smooth and tense, from stretching. When the liver
was sliced, the cut surface was smooth, presenting no appearance of lobules.
It was of a very pale red, mottled by white lines and spots. The
pale red portions were of close uniform texture, and semi-transparent,
having much the look of bacon-rind; the white lines and spots were
opaque. The opaque white matter consisted almost entirely of fat. Under
the microscope, it exhibited a mass of large oil-globules ; some free, others
in hepatic cells. In the interior of the liver, the fatty matter was deposited
chiefly along the small twigs of the portal and the hepatic veins, forming very
distinct white lines- Near the surface, it was in greater quantity, and in this
portion of the liver, some lobules were completely fatty, and large, and very
distinct to the eye, as in ordinary fatty degeneration. In the pale semi-
transparent portions, the hepatic cells were distinct, and contained no oil-
globules at all. No other objects were visible. The fat was not in sufficient
quantity to cause the great increase in the size of the liver, and the liver con-
tained hardly any blood.
The increased size of the liver, and the semi-transparency, probably de-
pended on some peculiar matter deposited in the lobules, — in the cells, or
between them.
The interstitial deposit of fat may have resulted from atrophy, or changed
form, of some elements of the substance of the liver. After the fat was
dissolved out with ether, the tissue of the liver had still a very peculiar
appearance, in many parts the compact uniform aspect of bacon.
On the surface of the peritoneum covering the intestines, there was a
deposit of granular lymph, having much the appearance of the semi-trans-
parent granulation of tubercle. Several of the bronchial glands were tu-
berculous, and there was one encysted tubercle in the left pleura; but there
were no tubercles in the substance of the lungs. The kidneys were in a state
of granular degeneration.
It is probable that, in this disease, as in the fatty liver, the sub-
stance to which the liver owes its increased size and its other pecu-
liarities, is a product of secretion, which, instead of passing oft' in
the bile, is retained in the liver. Chemical analysis would probably
disclose to us its real nature. The microscope fails to do this,
from the substance presenting no definite visible objects.
Scrofulous enlargement of the liver, like the enlargement from
deposit of fat, comes on without pain of the liver, or even tender-
ness ; a circumstance sufficiently accounted for by the gradual
and even manner in which the foreign matter accumulates, and
EFFECTS.
249
from its having no tendency to cause inflammation of the capsule
of the liver, or of the veins.
The passage of the blood through the liver is much more impeded
than in the fatty liver — probably, from the foreign matter being-
firmer, and less yielding, than oil-globules. In the case that has
been cited from Abercrombie, there was oedema of the legs, and
a considerable quantity of serous fluid in the belly. In my
brother’s patient, there was great ascites, and when the fluid was
drawn off by tapping, it rapidly accumulated again to the former
amount. In two cases, seemingly of the same kind, which have
fallen under my own care, there was likewise ascites.
In tins disease, as in the fatty liver, the secretion of bile — or, at
least, of the colouring matters of bile — may go on as usual, and the
complexion remain clear. But this is, perhaps, not so generally the
case as in the fatty liver. The matter deposited in the substance of
the liver, being firmer, is, probably, more apt to interrupt the secre-
tion, or the flow of the bile, and to render the complexion sallow.
Dr. Graves has remarked that in persons with scrofulous enlarge-
ment of the liver, the stools are variously coloured with bile —
“ one part of them will be bilious, another part clay-coloured ; they
will he yellow to-day, and pale to-morrow,” (Clinical Medicine, p.
566). He infers from this, that the office of the liver is per-
formed intermittingly ; that the liver secretes bile during a certain
period of the digestive process, then stops, and then secretes
again.
Scrofulous enlargement of the liver occurs in persons much
emaciated and in a state of scrofulous cachexy. It is, of course,
associated with the general symptoms attendant on this state, and,
by preventing the free passage of the blood through the liver, and
an adequate secretion and free flow of bile, and thus still further
impairing nutrition, must render them worse.
Enlargement of the liver, allied to the scrofulous enlarge-
ment, if not identical with it, sometimes occurs in persons whose
health is broken from the combined effects of mercury and syphilis.
This was, I believe, first distinctly noticed by Dr. Graves, who
gives the following account of a case of it. “About two years
since, I was consulted by an English gentleman, who had been
ill for a considerable time. The history of his case from the
250 SCROFULOUS ENLARGEMENT OF THE LIVER.
commencement was this. Three years previously he had venereal,
— used and abused mercury — was exposed to cold, and got peri-
ostitis. He now got into a had state of health, used mercury
a second time, obtained some relief, and then relapsed again ;
finally, after having used mercury three or four times, he was
attacked with mercurial cachexy, became weak and emaciated;
the periostitis degenerated into ostitis, producing superficial caries
and nodes of a bad character ; he had exfoliation of the hones
of the cranium, and rupia, and was reduced to a most miserable
state. Under our care the symptoms gradually disappeared; he
recovered to all appearance, and even got fat. He then caught
cold, and relapsed again. At last his liver became engaged ; he
was attacked with hypertrophy of the liver, ascites, and jaundice,
and died soon afterwards.” “ While this gentleman’s liver was
enlarging, there was no tenderness of the right hypochondrium on
pressure.” “ What is equally remarkable, he had no fever, and
the tongue was perfectly clean and moist during the whole course
of the hepatic affection.”
Dr. Graves says that he has since witnessed a similar train of
phenomena — syphilis, (abuse of mercury,) periostitis, enlargement
of the liver — twice in private practice, and once in hospital. In
not one of these cases was the liver tender on pressure.
From this account, it would seem, that the change in the liver
in these cases is very like that which occurs in scrofula, if not
identical with it. Mere fatty degeneration of the liver does not
cause ascites, which occurred in the case of which Dr. Graves has
given the details. It has been truly remarked by Dr. Graves, that the
mercurial and syphilitic cachexy very closely resembles scrofulous
cachexy. There is the same impaired nutrition, irritability, and
feverishness ; and the skin, the glands, and the hones, which princi-
pally suffer in the one, suffer also, and in much the same way, in
the other.
It is stated by Rokitansky, that enlargement of the liver, with
the same anatomical characters, is sometimes produced by pro-
longed attacks of ague. I have met with one instance in which
severe and long-continued ague in a boy was followed by scrofulous
disease of the glands of the neck and of the bones, and, subse-
quently, by great enlargement of the liver, and ascites. But,
here, the enlargement of the fiver was attributable to the scrofula,
and could not be considered the immediate effect of the ague. The
SIMPLE HYPERTROPHY OF THE LIVER.
251
liver very seldom gets much enlarged from ague. I have examined,
in the Seamen’s hospital, a great number of bodies in which the
spleen was enormously enlarged from ague, got in China, in the
West Indies, or on the west coast of Africa, hut in none of those
cases did I remark the liver to be much enlarged- After remittent
or yellow fever, the liver remains for a long time of a pale slate
colour, but it is not perceptibly enlarged.
Enlargement of the liver attended, like scrofulous enlargement,
with no inflammatory symptoms, now and then occurs, without our
being able to trace it to any of the circumstances specified. A
good instance of this is given by Andral, as an example of simple
hypertrophy of the liver.
Case. — Great enlargement of the liver, without apparent change of structure —
Jaundice — Jjoss of appetite — Gradual wasting — Coats of the stomach ex-
tremely thin and soft.
A gardener 33 years of age, entered la Char it e, with his skin of a greenish
yellow. He stated that the jaundice came on without assignable cause three
years before, and had continued ever since. Before the jaundice appeared,
his health was always very good, and, for the first year after this, he did not
feel ill; hut, in the two following years, he gradually grew weaker and
thinner, and lost his appetite, and, without actual pain at the epigastrium,
had a sense of weight and fulness there after eating. From time to time
he had diarrhoea.
On his admission to the hospital, the liver was felt extending low in the
belly, and was not tender. The tongue looked healthy, and the mouth was
not bitter. The bowels moved seldom; the stools were of moderate consist-
ence, and white. The pulse was not quick. There was very troublesome
itching of the skin.
A purely soothing treatment was adopted ; and the patient lived almost
entirely on broths. He gradually wasted away, and towards the close of life,
an abundant serous diarrhoea came on, which hastened his death.
On dissection, the liver was found of enormous size, reaching to the crest
of the ilium on the right side, and into the left flank. It did not seem at all
altered in texture, and did not contain much blood. The gall-bladder con-
tained only a serous liquid, very slightly tinged yellow. The gall-ducts were
empty, and their mucous membrane was of a greyish colour, but did not
seem altered in texture. The inside of the stomach was pale, and its coats
were so thin that they were transparent. No trace of the muscular coat could
be seen, and the mucous coat was hardly visible. All that was seen, was a
cellular woof, polished on the outside to form the peritoneum. There was no
other appreciable change in the intestinal canal. Tire mucous membrane of
the large intestine was white, and of its natural thickness and firmness.
252
SCROFULOUS ENLARGEMENT OF THE LIVER.
In this instance, the enlargement of the liver was attended with
decided jaundice, but not with ascites. In scrofulous liver, as in
cirrhosis, the passage of the blood through the liver is more im-
peded than the secretion and flow of bile. The belly is often dis-
tended with fluid, while the complexion is only slightly, if at all,
sallow. The gradual wasting, in this case, is sufficiently ac-
counted for by the jaundice and the impaired digestion that had
so long existed.
The diseases we have been considering were at one time regarded,
and by some pathologists are still regarded, as simple hypertrophy
of the liver ; the term, hypertrophy , meaning, as when applied to
muscles, mere increase of bulk, without change of structure. But
this is an erroneous view. The increased size of the liver, in the
fatty liver, in the scrofulous liver, and in other kindred states, de-
pends on the accumulation of some of the constituents of bile, or on
the presence of some peculiar matters secreted by the hepatic cells,
which, instead of passing off in the bile, are retained in the
substance of the liver. The diseases originate in faulty nutrition of
the hepatic cells. The pathologists who looked upon the enlarge-
ment of the liver in these cases as due to simple hypertrophy, were
at times much perplexed to account for the symptoms attending
it. Andral, in his remarks on a case of great enlargement of the
liver, consequent on syphilis and the use of mercury, which
he has given as an instance of simple hypertrophy of this organ,
expresses much surprise that there was not a corresponding
increase in the quantity of bile secreted. He says, “ One would
have thought, a priori, that when the nutrition of the liver was
increased in so extraordinary a degree, the secretion of bile would
have been more abundant in proportion. Such, however, was not
the case. During life, but little bile was discharged, and after
death the gall-bladder held only a small quantity, and this con-
taining, seemingly, more water and albumen than usual, as if,
while the nutrition of the liver became more active, its force of
secretion diminished. The following case will serve, perhaps, to
confirm this conjecture. It furnishes, in fact, an instance of
jaundice, without other change in the liver than simple hyper-
trophy.” (Clin. Med. iv. 305.) The case here referred to, is the
one related in the preceding page.
The thin and pale bile in the one caso, and the complete sus-
TREATMENT.
253
pension of secretion, ns evidenced by the complete jaundice,
in the other, lead to the conclusion, that the malady was not
simple hypertrophy, in the sense usually given to that term.
There is, indeed, great reason to douht, whether simple hy-
pertrophy, in the sense in which we understand it for muscles,
ever occurs as disease of the liver or of other glands. The liver,
like other organs, varies much in size, in different persons, quite
independently of disease, from mere peculiarities of formation ;
and, during the period of growth, it may become larger or smaller,
from some congenital malformation, or from some disease affect-
ing the development of the lung, or of some other organ. A liver
that has grown large from such causes, may properly he said to
he hypertrophied, hut such hypertrophy is not disease.
Scrofulous enlargement of the liver may often he detected, like
the fatty degeneration, hy the absence of pain or tenderness, and hy
knowledge of the circumstances in which it most commonly occurs.
In a child, much wasted by scrofulous disease of the glands or
of the hones, great enlargement of the liver, with ascites, that has
come on without pain or tenderness, is perhaps evidence enough
of this change. In a person of temperate habits in drink, whose
health has been much broken hy syphilis and mercury, the same
circumstances might perhaps warrant the same conclusion.
Where enlargement of the liver of this kind occurs in circum-
stances less significant, the real nature of the disease may he very
difficult to detect.
The treatment, in these cases, should have chief reference to the
state of the system — the peculiar cachexy — on which the faulty
secretion and the large size of the liver depend.
When the enlargement of the liver is consequent on scrofula,
our chief reliance must he on warm clothing ; sea- air and bathing;
a light nourishing diet, comprising a liberal allowance of animal
food and wine; and the preparations of iodine and iron, separate
or combined.
When the health has been broken hy the combined effects of
syphilis and mercury, warm clothing, a tonic regimen, iodide of
potassium, nitric acid, sarsaparilla, and guaiacum, are the appro-
priate remedies.
254
SCROFULOUS ENLARGEMENT OF TIIE LIVER.
In either case, the original malady is faulty assimilation, and,
if we can remedy this, we shall probably, in most cases, if not in
all, remedy the unnatural condition of the liver, and other se-
condary ailments.
My own experience leads me to think highly of frictions with
iodine ointment, long continued, in such cases. I have several
times seen an enlarged liver reduced to its natural volume by
iodide of potassium and frictions with iodine, or, simply, by these
frictions and saline purgatives. The matter deposited in the liver
does not become organised, like the fibrine poured out in inflam-
mation, and, if the general health mends, it may, in time, all pass
off in the bile, or be removed by absorption.
Dr. Graves gives very strong testimony to this effect. He
says : —
“ In persons below 30, the liver may become enlarged to a very
considerable extent, and yet return again to its natural size under
proper treatment. I could point out several persons in Dublin,
in whom the liver had been so much enlarged, that I thought
their cases hopeless, and yet they have recovered, and are at pre-
sent in the enjoyment of good health. The process by winch the
organ returns to its natural state and dimensions is generally slow ;
in two or three cases it occupied a space of time varying from one
to two years. I attended a gentleman some time ago with Mr.
Carmichael, and from the history of the case, as well as from the
symptoms present, we were induced to look upon it as incurable,
and yet the patient has completely recovered. The late Mr. Mac-
namara and I attended a lady who had a very remarkable enlarge-
ment of the liver, but in the course of a year the viscus diminished
so much in size, as to be very little above the normal dimensions.
Within the last year (1842), Dr. Stokes and I have treated suc-
cessfully an old gentleman between 70 and 80 years of age, who
had an enormously enlarged liver and ascites. We agreed to try
a combination of blue pill and hydriodate of potash. This he
took for nearly six months, and its use was attended by a visible,
almost daily, decrease in the size of the liver, and his general
health gradually improved. He took the pills for a couple of
months before Ins mouth got a little sore ; but full salivation was
not produced. He called on us a few weeks ago to thank us for
our successful treatment, and took no small pleasure in directing
TREATMENT.
255
attention to his altered appearance and renovated health. This is
a matter of no common interest ; for cases of this description have
been generally looked upon as beyond the reach of medical aid.
You should, therefore, be very careful in your prognosis of such
cases, and not give them up at once as incurable.” (Clinical
Medicine, p. 508.)
Sect. IV. — Excessive and defective secretion of bile — Unhealthy
states of the bile.
From the diseases just considered, we pass, naturally, to a very
important class of disorders : namely, those functional disorders,
in which too much, or too little, hile is secreted, or the bile secreted
is not healthy.
The secretion of bile may he disordered from organic disease
of the liver, which renders it incapable of adequately performing
its functions ; hut it may also be disordered without this, when
the portal blood, from which the materials of the hile are drawn,
is rendered unhealthy by medicines, by unwholesome food, by
faulty digestion or assimilation, or by defective action of some
other excreting organ. It may probably he disordered, too, from
the direct influence of anxiety or strong mental emotion. In any
case, the disordered secretion of bile is the effect of some other
disease, or of some cause that disorders other organs as well.
But the bile has a long course before it passes out of the body,
and serves an important office in digestion, and, on these accounts,
if it he in undue quantity, or unhealthy, however the change in
its quantity or quality may have been brought about, it may cause
various secondary disorders. In the first place, it may inflame or
irritate the gall-ducts, or the parts of the intestine with which it
is brought into contact. There is reason to believe that most of
the diseases of the gall-bladder and ducts, are. produced by ir-
ritating bile ; and there can be no doubt that various disorders of
the bowels result from the hile being in improper quantity or un-
healthy. But, besides these mere local effects, a faulty state of
the hile may render digestion imperfect, and in this way, may
impair nutrition ; and the noxious products of imperfect digestion
may he absorbed into the blood, and from this, again, many
secondary evils may spring.
EXCESSIVE SECRETION OF BILE.
257
Unhealthy states of the bile are analogous to unhealthy states
of the urine ; and may result in the same way, either from fault
of the secreting organ, or from an unhealthy state of the blood.
Unhealthy states of the urine have excited more interest, because
from our being able to collect and analyse the urine, we can dis-
tinguish them, and trace them to the disease of the kidney, or
to the faulty digestion aud assimilation, on which they depend.
They are some of them, as albuminous urine and saccharine urine,
almost pathognomic of certain fatal diseases which we might not
otherwise detect. Unhealthy states of the bile have less importance
in this sense, because we cannot distinguish them, and thus trace
them to their source, but in another sense they are more impor-
tant, from the bile serving an important office in digestion, and
not being merely excrementitial, like tbe urine.
From our not being able to collect the bile during the life of
the patient, and from the difficulty of analysing what may be
found in the gall-bladder after death, we have little knowledge of
unhealthy states of this fluid. We can often tell, by the symp-
toms, that too much bile, or too little bile, is secreted, and we
know something of the effects of this redundant or defective
secretion, but we have little knowledge of changes in the composi-
tion of bile, except what is derived from mere inspection.
We may, therefore, first consider, excessive secretion of bile ;
and defective secretion of bile.
Excessive secretion of bile. — The quantity of bile secreted, like
that of the urine, no doubt, varies very much, without disorder
of health, according to climate, season, and habits of life. In
certain circumstances, pointed out in a former part of this work,
an increased secretion of bile is necessary for the mainten-
ance of health. It can only be considered morbid, when, from
the great abundance of the bile, and perhaps from its being at the
same time altered in quality, secondary disorders are produced.
This frequently happens to persons on their first going to a hot
climate. It is of very common occurrence among Europeans in
India, and has been well described by Annesley, under the head,
“ Excessive Secretion of Bile.”
In the slighter degrees of this bilious disorder, the patient has
purging of bilious matter, which soon produces scalding of the
rectum, with slight sickness, a bitter taste in the mouth, and a
s
258
EXCESSIVE SECRETION OF BILE.
foul tongue, but without much fever, or the pulse being much
quickened. These symptoms rapidly subside, when the bile has
been got rid of by an emetic and purgatives.
In a more severe form, together with purging of bilious matter,
and vomiting, and foul tongue, there is a good deal of fever,
with pain and tenderness in the region of the liver, and the com-
plexion is bilious, or dusky. The illness resembles a slight form
of bilious fever. It would seem, that the irritating bile has
caused inflammation of the gall- ducts. There can be little doubt
that the bile, while it is increased in quantity, is also altered in
quality, and irritating.
In such cases, Annesley recommends bleeding from the arm, or
cupping over the liver, calomel and saline purgatives, and copious
draughts of hot water to dilute the irritating bile. Under tins
treatment, the patient soon regains his former health.
In this country the same form of illness is often seen, especially
among men of middle age, who have long been in the habit of
living freely. Such persons go on for some time, without appa-
rent indigestion, or other inconvenience, but, at length, get
what is called a bilious attack. This is marked by sickness
and bilious diarrhoea, a certain degree of fever, with a feeling of
general disorder, perhaps with headache, and by a foul tongue, and
turbid mine. In some instances, there is, likewise, a sense of
fulness, or uneasiness, in the region of the liver, and the com-
plexion is bilious. These complaints are, in most cases, readily
removed by brisk purging with calomel and salts, and the patient
enjoys again, for some time, his former health. If he returns to
his former habits, he, by-and-bye, gets a similar attack, which
perhaps is removed as before. In this way, he may go on for
years, bis general good health being only interrupted by an
occasional bilious attack of this kind, which, like a fit of gout,
seems to clear the system for a time. As remarked by Dr. Prout,
the acid and nnassimilated matters seem to accumulate in the
system, and to be thrown off periodically.
The readiness with which these attacks are removed, often
makes people regard them lightly ; but they are important, as evi-
dence of disorders, which, aggravated by time and by continuance
in the habits under which they have arisen, may end in some
organic disease, or in the total failure of those assimilating
processes on which nutrition depends. During the attacks,
TREATMENT.
259
signal relief is produced by a dose of calomel, or blue pill,
followed by saline purgatives. If there should be pain, or tender-
ness, in the region of the liver, and the patient can well bear it,
blood should be taken away by leeches, or by cupping. These
measures are generally sufficient for the time, but they do not
strike at the root of the evil. Exemption from future attacks,
and from the manifold and greater evils to which these disorders
may lead as age advances, can only be procured by a change
of habits. One of our objects in directing this should be to
increase the amount of oxygen inspired, and thus to consume in
respiration, or burn off, materials that would otherwise be left
for the liver to excrete. The means most efficacious for this
purpose, are sea-voyages, riding, or other exercise in the open air,
well- ventilated rooms, early rising, the cold or shower-bath, &c.
Too much indulgence in sleep, which so much reduces the activity
of both respiration and circulation, must be especially injurious, more
particularly in rooms that are ill-ventilated, as most bed-rooms are.
Another object, of equal, or still greater importance, should be to
limit in the food the supply of those materials — such as spirituous
liquors, butter, cream, fat, sugar, — which contribute directly to
form bile, or which increase the quantity of bile indirectly, by
serving as fuel for respiration. Some of those aliments — as
cream, and porter, for instance, — seem to be not only pernicious in
this way, but, also, by directly embarrassing the secreting function
of the liver.
From these considerations, it follows, that it must be especially
injurious for persons who suffer from the disorders we are consider-
ing, to indulge in sleep immediately after a full meal. To lessen
by sleep the activity of respiration at the very time when the ma-
terials consumed in this process are being poured in large quantity
into the blood, must lead in a two-fold way to accumulation of bile
in the system, and favour the occurrence of a bilious attack. Iu this
way may be explained the ill effects of suppers in disorders of this
class, and the well-known fact that a single indulgence of this kind
may bring on a bilious attack, in a person predisposed to it.
The medicines that are most efficacious are such as tend to
promote digestion, and to keep up the regular action of the
bowels. A few grains of rhubarb, alone, or in conjunction with
a grain of ipecacuanha, taken habitually at dinner ; or, if the
s 2
260
DEFECTIVE SECRETION OF BILE.
patient be plethoric, small closes of saline purgatives, taken occa-
sionally in the morning, are often of service.
Fluids taken in large quantity, in the form of mineral waters, or
pure water, have, also, often much efficacy in these disorders.
But our most effective resources are those hygienic regulations be-
fore pointed out, which have relation to the great conditions of air,
exercise, and temperature, on the one hand, and to the quantity and
quality of the food, on the other. In the degree of confidence he
places in these resources, and in the preponderance he gives them
over mere drugging in the treatment of disorders of this class, the
practitioner will give the best evidence of his real insight into
their nature, and of practical skill founded upon it. It adds not a
little to the value and importance of these means that they are
so free from hazard, and that they act in a way in which no
others can act, and therefore have no perfect substitute in any
direct medication. By appropriate purgatives, we may tempo-
rarily drain the liver and intestines of redundant bile, hut by
the means here pointed out, we prevent its formation, and attack
the evil in its source.
Diminished secretion of bile. — But disorder may likewise result
from the bile being secreted in too small quantity.
The office of the liver is to purify the blood, by freeing it from
the principles of bile, and by means of the bile, to assist in
digestion. The secretion of bile may, therefore, he defective in two
respects. Too little bile may he secreted to purify the blood, or,
without this, too little may be secreted to perform the necessary
part in digestion.
The simplest form of disorder arising from defective secretion of
bile, is where, while the blood is sufficiently freed from the prin-
ciples of bile and the complexion remains clear, too little bile is
secreted for the purposes of digestion. In such cases, diges-
tion is performed slowly, and nutrition suffers ; the bowels are
irregular, and generally confined ; the contents of the large intes-
tine often become too acid, or otherwise irritating, and produce
headache, or depression of spirits, or occasional diarrhoea. .
Disorder of this kind is sometimes produced hy too great ab-
stemiousness, to which weakly and nervous persons are often led
hy painful digestion, or uneasiness in the stomach after meals.
DEFECTIVE SECRETION OF BILE.
261
Many of the evils of this state may he lessened by supplying the
place of the bile, as a purgative, by aloes or colocynth ; but the
disorder will not be removed until the patient becomes less
abstemious. If the abstemiousness arise from painful digestion,
it should he our first object to remedy this.
Another form of disorder, attended with a very scanty flow of bile
into the intestine, if not with diminished secretion of bile, and of
which I have met with several well-marked examples, is this : —
A young person, delicate, and easily upset by any imprudence in
diet, has three or four times a year an attack of diarrhoea, which
lasts three or four days, or, it may be, a week, and which, during
that time, no sedatives or astringents will stop. The discharges,
while the diarrhoea lasts, are not at all tinged by bile. The
diarrhoea is attended by smarting at the anus, and by great languor
and debility, but not by sickness. As soon as the bile flows, the
diarrhoea immediately stops of itself. In these cases, the diarrhoea
and the general disorder cannot be ascribed merely to defective secre-
tion of bile or to the bile’s not flowing into the intestine. It is
probable that the illness begins in disordered digestion, and that
the irritating matters produced by this, stop the flow of bile into
the intestine, by causing spasm or inflammation of the mouth of
the duct, at the same time that they cause diarrhoea. The irri-
tating matters seem unnaturally acid. Magnesia produces con-
siderable relief.
Dr. Prout has ascribed a variety of similar disorders to excess
of acid in some part of the intestinal canal, especially the caecum.
He says, “ Excessive acidity of the caecum is generally accom-
panied by a deficient secretion of bile ; and, sometimes, by a
complete temporary suppression of the bilious discharge, ap-
parently from spasmodic constriction of the common gall-duct ;
or, it may be, of the biliary ducts themselves. In this state of
things, all individuals feel more or less of uneasiness ; but the
point we wish to mention is, that certain individuals under these
circumstances experience what is called nervous headache. This
species of headache is frequently accompanied by nausea ; is
confined to the forehead ; and, when severe, produces complete
intolerance of light and sounds, and a state of mind bordering on
delirium. After a greater or less period the pain ceases ; some-
times quite suddenly; and the remarkable circumstances to be
mentioned here are, that this sudden termination is preceded by a
262
DEFECTIVE SECRETION OF BILE.
peculiar sensation (sometimes accompanied by an audible clicking
noise) in tbe region of the gall-ducts ; that immediately after-
wards, a gurgling sensation is felt in the upper bowels, as if a
fluid was passing through them ; and that in a few seconds,
when this fluid, which we suppose to be bile, has reached the
coecum, the headache at once vanishes like a dream. One of the
greatest martyrs to this species of headache I have ever seen, in-
variably experiences the train of symptoms above described ; and
I have witnessed it in a greater or less degree in many in-
stances ; indeed I have experienced it in my own person.’’
(Stomach and Urinary Disorders, 3rd ed., p. 75.)
During attacks of this kind, our object should be, to neutralise
the excess of acid, and to carry off this and other offending
matters, by a mild but effectual purgative. Dr. Prout recom-
mends the compound decoction of aloes, with magnesia, as well
adapted to fulfil these objects. He says, “ Drastic purgatives, in
general, should be avoided ; for though they sometimes give im-
mediate relief, they usually leave the patient more inveterately
disposed to the disease.” (Id. p. 88.) I have lately had
striking proof of the truth of this remark. A liealthy-looking
man, near fifty, who has habitually difficult digestion, and costive
bowels, with occasional heart-burn, has had for a great number of
years frequent attacks of headache, like those described in the
passage just cited from Dr. Prout. The headache generally
comes on at night, and is confined to the forehead. It is ex-
tremely severe, and, while it lasts, the brow feels hot, the eyes
water, and the urine is turbid. If let alone, it always lasts two or
three days, but for many years, he was in the habit of getting
rid of it by Morrison’s Pills. In the evening, as soou as the
headache came on, he took sixteen of Morrison's Pills. In the
course of three hours, these purged him violently, and the head-
ache was relieved at once. He continued to treat himself in this
way for several years, but gave the plan up at last, from the head-
aches becoming more severe and more frequent. Under a re-
stricted diet, and by taking daily at dinner a few grains of
rhubarb, with a grain of ipecacuanha, and, now and then, a little
magnesia or potash, to correct acidity, — the headaches have
become again much less frequent. In all diseases of this class,
resulting from faulty digestion or assimilation, — which manifest
themselves now and then in a bilious attack, ora severe headache,.
DEFECTIVE SECRETION OF BILE.
263
or a fit of gout, — our object must be, uot merely to remedy tbe
present disorder, but to change those habits of life, by which recur-
rence of the disorder is favoured.
Another class of disorders is where the secretion of bile is de-
fective, not as regards digestion merely, hut as regards the blood ;
where the blood is not sufficiently freed from the principles of the
bile, and the complexion is jaundiced, or bilious.
This may even happen where a- large quantity of bile is se-
creted. The bile may be in excess as regards the intestines, and
cause the bilious diarrhoea before described, and yet may he
secreted in too small quantity to purify the blood, and the com-
plexion be bilious, or sallow. Disorder of this kind is, in general,
of short duration. A dose of calomel and a few brisk purgatives,
carry off the redundant bile, and, if no mischief have been done
to the gall ducts, all is soon well. The malady depends, not on
defective power in the liver, but on heat of climate, or too rich
living, or indolent habits, by which the principles of bile are
formed in large quantity in the system.
But it often happens that, from some fault in the liver, too little
bile is habitually secreted both to purify the blood and to forward
digestion, even when the habits of life, and other circumstances, are
most favourable to health. Where there has been adhesive in-
flammation of branches of the portal vein, or where adhesive
inflammation in the areolar tissue about the vein has oblite-
rated many of its small twigs, and the parts of the liver, which
those branches or those twigs supplied, are atrophied ; or where
from the more interstitial deposit of fibrine, in cirrhosis, the
original substance of the liver is divided into small masses of
lobules, which, by the subsequent contraction of the effused
fibrine, get more or less atrophied ; or where, in consequence of
the bilious disorders of hot climates, or the remittent fevers so
common in them, or, it may be, of long continued indigestion
in any climate, the liver has been permanently damaged in its
secreting element, — the liver may he inadequate duly to perform
its office, and the health be permanently impaired in conse-
quence.
The various forms of adhesive inflammation which lead to
atrophy of parts of the liver, are brought on, in almost all
cases, by spirit-drinking. The more direct injury, to the se-
264
DEFECTIVE SECRETION OF BILE.
creting element of the liver, is more commonly the effect of
long residence in a hot climate, and of the various bilious dis-
orders incident to it. Habitual defective secretion of bile is,
therefore, met with most commonly in persons who have been
hard drinkers, or have lived long in hot climates. The condition
of the liver in these two classes of persons differs in this, that in
the spirit- drinkers there has been a deposit of fibrine about the
vessels, which by its contraction causes impediment to the flow of
the portal blood ; while in persons whose liver has been damaged
by long residence in a hot climate, without intemperance, no such
impediment exists. But the condition of the liver is so far alike
in the two classes, that the secreting element has been damaged
in both, and what is left of it is not enough, or is not active
enough, for the purposes of health.
In consequence of this inadequate secretion of bile, digestion
is slow, and imperfectly performed, the bowels are habitually
costive, there is a falling off in flesh and strength, and the
skin is more or less sallow and dry. In this state, a person may
go on for years, with very little effective liver left. The secretion
of the liver, though necessary for proper nutrition, is not im-
mediately necessary to life. We have seen that from closure of
the common duct, the liver may be completely destroyed as a se-
creting organ, and life may yet persist for many months. Many
of the persons who return from India with dry wrinkled skins and
greenish complexions, who, if we consider the liver merely as a
secreting organ, have truly, to use the common phrase, very
little liver left, may yet, with proper care, enjoy moderate com-
fort for years. In the advauced stages of cirrhosis, too, a person
may still live on, when but a comparatively small portion of the
original secreting structure of the liver remains ; and, here, there
is an additional cause of wasting, in the impediment to the pas-
sage of the portal blood. But, in all such cases, where from some
damage done to its secreting element, the liver is permanently
inadequate to its office, though life may continue, digestion and
nutrition are imperfect, the person grows gradually thinner, and
at length dies much wasted.
In disorders of this class, which result from organic disease, the
health cannot be perfectly re-established, but it may be very much
mended, and life may be much prolonged. Nothing contributes
to this so much as strict attention to diet. The person should
TREATMENT.
265
take ft sufficiency of light nourishing food, hut should abstain from
all rich meats, and, as much as possible, from fermented drinks,
which tend to induce a bilious state of the system, and thus render
the liver still more inadequate to its office. The bowels should he
regulated by some mild, but effectual, purgative. A pill of
aloes, or of aloes and rhubarb, taken habitually at dinner,
answers the purpose well. The patient should have the advan-
tage, where possible, of a pure, moderately cool, air, which has
great efficacy in bilious states of the system. When the weather
permits, airing in an open carnage, or if it can he borne, riding on
horseback, short of fatigue, will be productive of good. The simple
hygienic measures — regulation of diet, and provision for free re-
spiration— are the more important, because, as before remarked,
there is no substitute for them. Benefit may also be obtained by
various medicines, some of which seem to act by rendering the
secretion of less bile necessary; others, by rendering the liver
more active, and in this way increasing its secretion.
The medicine of the former kind in most repute, is the so-
called nitro-muriatic acid, which has been long celebrated in India
for its efficacy in chronic functional derangements of the liver. In
India, it is used in foot-baths, and in lotions to the side, as well
as given internally. *
Of medicines that render the secretion of the liver more active,
and thus increase the flow of bile, or, as they have been termed,
cholagogiies, the most energetic is mercury. In the occasional
bilious disorders of persons who have no organic disease of the liver,
a dose of calomel, or blue pill, followed by a brisk saline purgative,
produces more speedy relief than anything else, and is more likely,
therefore, to prevent inflammation, or ulceration, of the gall-ducts,
which seems generally to result from the irritation of unhealthy
* Annesley directs f^iv. of nitric acid, and f 5iv. of muriatic acid of the
strength of the London Pharmacopoeia, to he added to f gviii. of pure water,
and the mixture to be labelled, “ the nitro-muriatic solution.” From f 5b to
f 5ib of this solution to a pint of water is the strength used for lotions and
foot-baths. For a foot-bath, the water should be nearly the temperature of
the blood, and the feet should be kept immersed in it for twenty minutes, or
half an hour, every night at bed- time. When used as awash, it should be
of an agreeable temperature, and should be applied assiduously to the trunk
and insides of the thighs for a quarter of an hour daily.
266
UNHEALTHY STATES OF THE BILE.
bile. Occasionally, and under these circumstances, and especially
in persons of full habit, mercury may be given with great advan-
tage. But its frequent use, in any case, may lead to much mis-
chief. When the liver has been accustomed to the stimulus of
mercury, no other medicine will sufficiently excite its action. The
person is thus led to the habitual use of this medicine, and, after
a time, the constitution is undermined by it. In the class of cases
we have just been considering, where, from organic disease, the
liver is inadequate to its office, and nutrition has suffered much in
consequence, mercury, although even here it may relieve for the
moment, will almost invariably do harm. It increases the activity
of the liver, at first, but seems to leave it weaker tlian before, and
if frequently resorted to, the nutrition of the patient, impaired by
the original disease, is still further impaired by the drug. In all
such cases, we should be content with milder medicines, which in-
crease the secretion of the liver without having any permanent
deleterious effect on the system. The best medicine of this class
is taraxacum ; which may be given alone, or in conjunction with
the nitro-muriatic acid.
In all organic diseases of the liver, where the secretion of bile
is habitually deficient, and nutrition is impaired in consequence,
the person should be warmly clad, and should avoid all causes of
exhaustion. Fatigue, and lowering remedies, exhaust the strength,
and draw, as it were, upon the capital of the patient, when this is
very difficult to recruit. The disease destroys its victim, not by
sudden illness, but by gradually wasting the strength. The more,
therefore, this is economised, the longer will the patient live.
The bile altered in quality.— Few analyses have been made
even of healthy human bile. The attempts of Berzelius, and
others, to ascertain the composition of bile, have most of them
been made on ox-bile, which can be more readily obtained fresh,
and can be obtained in larger quantity than human bile. It can-
not, therefore, excite surprise, that little is yet known by chemical
analysis, of the changes produced by disease in human bile.
The only morbid states of bile ascertained in this wray consist in
the presence of a free acid ; in the presence of urea ; in the pre-
sence of some medicines that pass off in the bile ; and in altered
qualities of some of the natural constituents of bile.
UNHEALTHY STATES OF THE BILE.
267
Very few instances are recorded in which the bile was found to
he acid. One such instance has fallen under my own observation.
In a woman, who died, in the autumn of 1843, in King’s College
Hospital, of cancerous ulceration of the rectum and granular
kidney, the bile in the gall-bladder, which was of a pale amber
colour, reddened litmus paper distinctly. Unfortunately, no ana-
lysis of it was made. In dark-coloured bile, alkalinity, or acidity,
cannot he readily detected by means of test-papers, on account of
the stain which the colouring matters of the bile give to the
paper.
Urea has been found in the bile, only, I believe, in persons dead
of cholera. It was first detected by Dr. O’Shaughnessey, in bile
which he analyzed at the request of Dr. Roupell, and which was
taken from a person who died of cholera, after having made very
little urine for eight days. The bile did not differ in appearance
from ordinary bile, but contained in one thousand parts, six of
salts, and three of urea. (Roupell on Cholera, p. 84.)
Various medicines have been found in the bile, hut our list of
those which pass off in this way is, doubtless, very imperfect. It
is probable that most of the medicines which increase the secretion
of bile, pass off, in part, either bodily or more or less changed,
through this channel.
The observations made by chemical analysis, on the altered
qualities of the natural constituents of bile, are very few, and of
little value. They are sufficient to show that some of the natural
constituents of bile become changed in disease, which might have
been anticipated from the readiness with which the principles of
bile enter into new combinations; but they do not tell us in what
those changes consist.
The difficulty of analyzing bile, and the circumstance that
human bile can only he obtained in small quantity, and many
hours after death, when the bile in the gall-bladder is probably al-
ready changed by decomposition, sufficiently account for the
observations of this kind yet made being so few, and so little to be
relied on.
The most valuable observations that have been made on altered
qualities of the bile, and these arc few and imperfect, relate to
changes that can he at once recognised by the senses.
In some cases, the colouring matter is deficient, the bile found
8
268
UNHEALTHY STATES OF THE BILE.
even in the gall-bladder is pale and thin, and has not its u=ual
bitterness, and the lining membrane of the gall-bladder and ducts
is hardly stained by it. This condition of the bile is found most
frequently in those diseases which change the structure of the
whole liver. It is not uncommon in cirrhosis ; and is now and
then remarked where the liver is much enlarged from interstitial
deposit of fat, or other morbid products of secretion.
But occasionally the bile has these characters when there is no
apparent disease of the liver itself. I have met with it in dropsy
from granular kidney, and in two cases of purulent phlebitis, with
scattered abscesses in the lungs and other parts of the body. In
neither of these two cases were there abscesses, or other marks of
disease, in the liver.
In other cases, the bile is unusually dark-coloured, and thick.
This may be from mere concentration of the bile in the gall-
bladder. If the bile remain long in the bladder, much of its water
is absorbed, and it becomes in consequeuce very dark coloured,
and viscid. This is usually found to he the case in healthy per-
sons who die from some accident after long fasting. In persons
who die during the cold stage of malignant cholera, where the
whole body is drained of its water, the bile in the gall-bladder is
always of a dark olive, and viscid. In persons who die of phthisis,
the bile in the gall-bladder, even when the liver is fatty, is often
very dark-coloured, and viscid ; most probably from remaining
there long, and becoming concentrated, in consequence of the repug-
nance to food and emptiness of the stomach and intestines, that is
common in the advanced stages of phthisis.
But the bile may he secreted unusually viscid, and unusually
dark-coloured, and may present these characters in the hepatic
ducts, when the passage of the ducts is free. This is, perhaps,
most common in hot climates, where the essential principles of the
bile are formed in large quantity in the system. Annesley states
that very commonly in India, in persons who die of diseases of
the liver, or of other organs, the gall-bladder is found distended
with thick, acrid bile, and the hepatic ducts are completely gorged
with bile of this character, without any apparent organic change
sufficient to account for the circumstance, and without other im-
UNHEALTHY STATES OF THE BILE.
269
pediment to the escape of the bile than that which arises from its
own viscidity. Where the secretion of bile is very abundant, a
partial obstruction of short continuance, may cause great accumu-
lation of it in the gall-bladder, and in the liver itself. Annesley be-
lieves, that, in India, this accumulation of bile occurs, not only in
the course of other disorders, hut as an ailment of itself — the dis-
turbance in the system resulting solely from the retention of bile in
the liver, and the subsequent irruption of the long retained bile
into the intestinal canal. He says, “ The earliest symptoms
of which the patient generally complains, when he attends to his
sensations and state of health, are, clamminess and foulness of the
mouth, fauces, and tongue, with a bitter taste, particularly in the
morning : a sense of distension and weight at the epigastric
region and at the precordia, frequently with a sense of coldness
and sinking in the same situations ; slight anxiety; acid and acrid
eructations about three or four hours after a full meal, with pain-
ful fulness at the epigastrium, and difficult digestion. The patient
often complains of headache, pain in the back or loins, uneasiness
under the shoulder-blades, fulness and pain in the region of the
liver, particularly when pressure is made at the time of his taking
a full inspiration ; and of aching in his knees, shoulders and limbs ;
his countenance being pale, sallow, or muddy, and the coujuuctivae
more or less tinged of a yellowish hue. The state of the pulse is
different in different cases. It is often slow and full, and some-
times it is irregular in frequency and strength ; occasionally it in-
termits, and not unfrequently becomes quick, but oppressed upon
the least motion or exertion. The urine is generally high-co-
loured, and deposits a brownish sediment. The stools are often
costive, sometimes light or clay-coloured, and frequently tenacious.
When the accumulated bile is discharged into the alimentary
canal, much constitutional disturbance generally arises, according
to the qualities which this fluid may have acquired from its reten-
tion. The pulse now becomes quick, and often irregular ; vomit-
ing and purging, with griping, pain and anxiety, often supervene,
sometimes with spasms. Thirst becomes urgent, and the tongue,
which was before foul, is now excited, often dry, and its papillae
large, distinct, and erect.” (Yol. i. p. 329.)
“ It sometimes occurs that the inordinate flow of morbid bile
into the duodenum, particularly when it has been long retained,
270
UNHEALTHY STATES OF THE BILE.
and during close, warm, and moist states of the air, occasions
faintness, the most alarming state of sinking, and prostration of
the vital energies.” (Id. p. 331.)
In this country, a bilious disorder attended with symptoms very
like those described by Annesley, now and then occurs, especially
in women about the middle of life, and is probably occasioned, as
Auuesley supposes, by temporary retention of viscid, or unhealthy,
bile.
But the retention of thick and unhealthy bile may lead to other
mischief. When healthy bile is much concentrated, it throws
down irregular, solid, particles of green or yellow biliary matter,
which may he distinctly seen under the microscope, and which, if
the concentration be carried far enough, render the bile gritty, or
even form a complete magma. If the bile be unusually dark-
coloured and thick, and otherwise unhealthy, when first secreted,
and especially if it remain long in the gall-bladder, solid biliary
matter may be deposited in the bladder, and may form the nucleus
of a gall-stone. Almost all gall-stones found in the human gall-
bladder, have a dark nucleus of concrete biliary matter, which is
surrounded by cliolesterine, mixed with variable proportions of
the colouring matters of bile. The biliary matter falls down in
solid form more readily in the gall-bladder, because the bile,
during its stay in the bladder, becomes concentrated. The bile in
the hepatic ducts is usually much more watery, and lighter in
colour, than that found in the gall-bladder. It very seldom hap-
pens that solid biliary matter is deposited in the hepatic ducts, in
man. Gall-stones are found almost solely in the gall-bladder, and
in the cystic and common ducts. #
Another morbid state of bile, of great importance from its con-
tributing largely to the formation of gall-stones, is where the bile
contains sparkling scales of cliolesterine. I have never found this
in the hepatic ducts. Cliolesterine seems in most cases to he formed
in the gall-bladder, or at least to he there deposited in crystals. The
presence of visible scales of cliolesterine in the bile is generally as-
sociated with disease of the gall-bladder. When the coats of the
gall-bladder have undergone the fatty degeneration, before spoken
* In stall-fed oxen, whose bile, from the nature of their food, is perhaps
richer in colouring matter, gall-stones composed entirely of the colouring
matters and the resinous principles of bile, are frequently found in the he-
patic ducts.
UNHEALTHY STATES OF THE BILE.
271
of, the cystic bile always abounds in crystals of this substance.
But crystals of cholesterine are now and then formed, when the
coats of the gall-bladder seem healthy. *
These considerations lead us to gall-stones, which, from their
palpable form, tlieir frequency, and the distressing symptoms they
often occasion, have excited more attention than any other result
of unhealthy bile.
* Cholesterine may doubtless be secreted by any part of the mucous lining
of the biliary passages. The “ knotty tumors” described in the next chapter,
prove an abundant secretion of it from the hepatic ducts under certain cir-
cumstances.
272
Sect. V. — Gall-stones.
Gall-stones, as already remarked, are usually formed in the
gall-bladder, where the bile becomes concentrated from absorp-
tion of part of its water, and often otherwise altered by un-
healthy secretions from the coats of the bladder, and where it is
longer stagnant than in the ducts. But it now and then happens,
that gall-stones form in the substance of the liver, in branches of
the hepatic duct. These hepatic gall-stones are always very
small, of irregular, tuberculated, form, and of a dark olive, almost
black colour; and are composed of solid biliary matter, more
or less altered, and mucus. They probably originate, in most
cases, in inflammation of the hepatic ducts. In consequence of
this, a duct becomes closed at some point. The bile then accu-
mulates in the portion beyond, and after being some time stag-
nant, is inspissated by the absorption of part of its water, and
throws down solid grains of biliary matter. These grains of biliary
matter, and the inspissated bile that remains, are cemented by mucus
secreted by the coats of the duct, so as to form a small calculus.
The way in which gall-stones in the substance of the liver are
formed, explains the circumstance, remarked by Cruveilhier and
others, that they are often encysted. The cyst, like some other
varieties of cyst occasionally found in the liver, is formed of the
coats of the gall-duct. The duct is distended into a pouch by
the foreign matter, and being closed on each side of this by in-
flammation, forms, if the foreign body be not absorbed, a perma-
nent cyst.
Gall-stones of the same hind, composed chiefly of grains of
solid biliary matter, with inspissated, and probably otherwise
altered bile, cemented by mucus, are now and then found in the
gall-bladder. They are usually small, and are at once distin-
guished from ordinary gall-stones, by their irregular, tuberculated
form, and their almost black colour ; circumstances which have led
to tlreir being compared, and not unaptly, to black pepper. They
VARIETIES.
273
arc heavier than ordinary gall-stones, and do not bum so readily,
and, when burnt, sometimes leave a considerable quantity of
carbonate and phosphate of lime,* derived probably from the
mucus by which the grains of biliary matter are cemented.
Little is known of the circumstances which lead to the forma-
tion of this kind of gall-stone. Dr. Prout has hinted that they
are associated with a tendency to the formation of oxalic acid, and
to that of malignant disease, more especially of the liver.
I have met with gall-stones of this kind in two cases of which
I have kept notes. The first was that of a sailor, 54 years of age,
who died, in the Dreadnought, of fever, in July, 1837, and who for
seven months previously, had been employed on the Thames. The
liver appeared healthy, and no marks of disease were noticed in
the gall-bladder. There were some small serous cysts in the
cortical substance of each kidney ; and at the back part of the
upper lobe of the left lung, the surface for the breadth of half-a-
crown was puckered, and the pulmonary tissue beneath indurated
— the consequence of a cavity which had formed there at some
former period, and which was not quite closed. There were no
tubercles, or other marks of former disease, and the only recent
changes of structure were ulcers in the lower part of the ileum,
the result of the fever. The gall-bladder contained a great num-
ber of very dark mulberry-looking calculi, all of them about the
size of small peas. When dried, they were very friable, and
were found to be composed of solid black grains, cemented by a
greenish matter, that consisted of mucus and inspissated bile.
The second case was that of a man, aged 62, who died in the
summer of 1838, also of fever. The gall-bladder contained three
irregular black calculi, apparently composed of biliary matter and
mucus, the smallest of the size of a cherry-stone. There was
a calculus of the same kind in one of the hepatic ducts. The
mucous membrane of the gall-bladder was somewhat thickened, but
was not ulcerated. Besides the calculi, there was in the bladder
a small quantity of yellow gritty bile.
In the Museum of King’s College, is a dry preparation, left to
the College by the late Dr. Hooper, showing a great number of
gall-stones of this kind in the bladder in which they were found.
(See Plate 1, fig. 1, in which some of these gall-stones are repre-
sented.) The coats of the bladder seem to have been healthy.
* Prout. Stomach and Urinary Diseases. 3rd Edition. Introduction, p. 65.
T
274
GALL- STONES.
One of the conditions requisite for the formation of this kind of
gall-stone seems to he a healthy state of the gall-bladder. When
the coats of the gall-bladder are diseased, cholesterine is usually
formed, or at least takes the solid form, in large quantity in the
gall-bladder, and if there be a small mass of inspissated bile, to
serve as a nucleus, this cholesterine collects round it, and produces
the more common kind of gall-stone.
Gall-stones composed almost entirely of inspissated bile, are
seldom found in the human gall-bladder, and when found there
are usually very small, on account, it would seem, of the great
tendency to the formation of cholesterine; but in the gall-bladder
of the ox, cholesterine seems less apt to be formed, and gall-stones
composed almost entirely of the colouring matters of bile are not
unfrequently met with. The gall-stones found in the gall-bladder
of the ox, have been long esteemed as a pigment. (Prout.)
Gall-stones from the human gall-bladder are almost always
composed in great part of cholesterine, mixed with a certain
quantity of the colouring matters of bile. They have all a
nucleus, which is generally of a dark olive or black colour, and
apparently composed, in most cases, of inspissated and altered
bile, cemented by mucus.
The shape, and size, and appearance of gall-stones varies very
much, according to the circumstances under which they are formed.
When there is only one gall-stone in the bladder, it may grow
to the size of a hen’s egg, but is seldom found so large. While
it remains small, and can move freely in the bladder, it is generally
spherical, but when it becomes so large that it is girthed by the
bladder, or can no longer roll freely in it, it grows most at
tbe ends which are not subject to pressure, and so becomes some-
what egg-shaped.
Large solitary gall-stones, with the exception of their nuclei,
are composed almost entirely of cholesterine, and are, consequently,
white and crystalline. They have a soapy feel, and when placed
in the flame of a candle, readily melt, and burn with a bright
flame. Sometimes the cholesterine is deposited quite pure, and
the gall-stone is then quite white, like a ball of camphor, or of
white marble. The surface is generally a little rough and dull,
but it readily takes a fine polish. When these round or oval stones
are sawn through the centre, they are seen to be crystallised in
VARIETIES.
275
rays, -which converge towards the nucleus. (See Plate 1, fig. 2,
which represents the section of a gall-stone of this kind.)
It sometimes happens that two round or oval gall-stones are
found in the bladder, when, by some constriction at its middle,
the bladder is divided into two distinct pouches.
When the cystic duct has been closed, and the coats of the
gall-bladder are healthy, the stone is sometimes closely embraced
by the gall-bladder, and marked by its rugae, so that it has its
surface tubercular, like tbe mulberry.
But it is much more common to find many gall-stones in the
bladder than a single one ; and occasionally they are found in
almost incredible numbers. As many as three thousand have
been counted in a single bladder.
When there are many gall-stones in the bladder, they differ
in form and appearance from solitary gall-stones. Instead of
being round or oval, they have, usually, plane, polished, faces
— the effect of the mutual attrition of the stones, which polish
each other tbe more from the presence of the minute crystals of cho-
lesterine contained in the bile.
When the stones are few in number, and can shift their rela-
tive positions in the bladder, they may attain a considerable
size, and sometimes become very irregular in form, often, as re-
marked by Haller, very much resembling the bones of the wrist.
In other instances, their forms are strikingly regular. In the
spring of 1837, I found in the gall-bladder of a man, who died
at the age of 60, of scurvy, eight gall- stones, little larger than
peas, all of them veiy regular tetrahedrons. It is difficult to
imagine how forms so regular are produced.
Gall-stones which have smooth flat faces generally contain more
of the colouring matters of bile than large solitary gall-stones, and
are usually of a variegated greenish and brownish colour. When
sawn through the centre, they are found to be laminated and to
have a nucleus, which seems generally composed of dark biliary
matter. The successive laminae are sometimes very fine, and even
then, when the face is polished, are generally distinctly visible from
being of different shades of brown and green. When a section is
made through the centre and its surface polished, together with the
concentric laminae, we may still see rays converging towards the
centre as in the white oval calculi of cholesterine, (see Plate 1,
fig. 3.) In both varieties of calculi, the cholesterine is deposited
T 2
276
GALL-STONES.
in the same way, but in the pure cholesterine calculi, the appear-
ance of concentric laminte is not produced, because the successive
layers are not tinged of different colours by the bile.
Gall-stones which appear distinctly laminated, have sometimes a
crust of pure cholesterine, which is probably formed after the
entrance of bile into the bladder has been prevented by one of
them becoming impacted in the cystic duct. (See Plate 2, fig. 2.)
Now and then, but rarely, we find this order reversed. A
gall-stone almost of pure cholesterine, and therefore uniformly
white, has a crust, of which the successive layers are differently
coloured by bile, and which, therefore, appears laminated.
The different gall-stones found in the same bladder, have
almost always the same characters. They are laminated alike,
their nuclei have the same appearance, and if one of them have a
crust of pure cholesterine, they all have it. From tins it is pro-
bable, that they are generally formed at the same time, and not in
succession.
A circumstance that seems almost necessary to the formation
of gall-stones, is the presence of a small mass of solid biliary,
matter, or inspissated bile cemented by mucus, or some other
substance, about which the cholesterine may collect. Almost all
gall-stones have a nucleus, not of cholesterine, which must, of
course, have existed before them. An excess of cholesterine is
not, of itself, sufficient for the formation of gall-stones. In a
case which I have related in a former part of this work, the mouth
of the cystic duct seemed to have been long blocked up by a
gall-stone. The gall bladder, whose coats had undergone the
fatty degeneration, contained a viscid mucus sparkling with scales
of cholesterine, but no other gall-stone. Another specimen pre-
cisely of the same kind, was sent to King’s College Museum,
during the present summer, by Mr. Lingen, of Hereford.
(King’s College Museum, Prep. 268.) Gall-stones are formed in
numbers in the gall-bladder, only when the bile can flow into it
through the cystic duct. But the presence of bile, even of dark-
coloured bile, and aplentiful formation of cholesterine, are not alone
sufficient. On more than one occasion I have found in the gall-
bladder very dark-coloured viscid bile, sparkling with scales of
cholesterine, when there were no gall-stones. It seems necessary for
the formation of a gall -stone, that there should be a nucleus of
VARIETIES.
277
some other substance, about which the cliolesterine may crystal-
lise. It would appear from some of the published descriptions of
gall-stones, that a particle of cliolesterine may of itself serve as a
nucleus of a solitary gall-stone, but this happens very seldom. In
almost all cases, the nucleus is some substance different from cho-
lesterine, and from its dark colour is probably, in most cases,
composed chiefly of altered biliary matter and mucus. The
nucleus presents different appearances in different gall-stones.
In some it is round and compact, even when the gall-stone has
been long kept, and is perfectly dry : in others, it is of irregular
outline, and, in the drying, contracts so as to leave a hollow in
the centre of the stone. (Plate 1, fig. 4.) In some, the nucleus
is a mere point ; in others, of the size of a small pea. But, as
before remarked, when there are many gall-stones in the same
bladder, their nuclei have, usually, all the same characters. If one
nucleus is small, all are small ; if one is compact, all are com-
pact; if one stone have a hollow in its centre, all have it.
The different appearances of the nuclei of gall-stones in
different cases would lead us to expect corresponding differences
in their chemical composition ; and probably a careful analysis
of the nuclei of gall-stones would throw much light on the
proximate cause of their formation. Little more is known at pre^
sent, than that the nuclei of most seem to be composed chiefly of
altered biliary matter and mucus. In a few instances, however,
some other substance has been found in the nucleus.
Bouisson states that he has a small solitary gall-stone, whose
nucleus seemed to he formed of blood ; (Bouisson, p. 243 ;) and
one, the size of an almond, which he found in the hepatic duct
of an ox, in which the nucleus is a fragment of a fluke. He
cites an instance, represented by Lohstein in his plates of
morbid anatomy, where a large gall-stone had formed about a
dried lumbric worm. The gall-stone was found in the common
duct of a woman, 68 years of age, who died of colliquative
diarrhoea, in an hospital at Strasburg. There were one hundred
and eighty-five worms of this kind in the stomach, and thirty in
the branches of the gall -ducts, which were very much dilated.
He cites another instance, where a gall-stone had formed about a
pin in the gall-bladder ; and another, where the nucleus of a
gall-stone is said to have contained globules of mercury. This
last gall-stone, which was of the size of a prune, and composed
10
273
GALL-STONES.
chiefly of cholesterine, was taken from a person to whom mercury
had been given for syphilis. The nucleus of the stone, when
melted by heat, is said to have presented many globules of
mercury.
Gall-stones are very light considering their size. When fresh
from the gall-bladder, they usually sink, if placed in water.
When they have been kept long, and are quite dry, most of them
float, until they have imbibed a certain quantity of the water, when
they sink slowly. Their specific gravity depends chiefly on the
relative proportion of cholesterine and colouring matter. Choleste-
rine is lighter than water ; the colouring matters of bile are heavier.
The lightest gall-stones are therefore usually those which contain
the largest proportion of cholesterine. The weight of gall-stones,
especially when dry, will, of course, vary also with the character
of their nuclei.
Mr. Taylor has lately described a calculus, which he found
among the calculi in the Museum of the College of Sur-
geons, and which he supposes to he biliary, composed chiefly
of stearate of lime. It was oval, slightly flattened, an inch and
a half in length, rather more than an inch in thickness, and about
an inch and a quarter in breadth. Its surface was of a dirty
white, and it had the greasy feel of cholesterine calculi. It floated
in water, and when applied to the tongue left an impression of
bitterness. It yielded readily to the knife, and the cut surface
had a polished appearance. It was composed of white and
reddish-yellow layers, arranged concentrically, and alternating
with each other. The layers were easily separable. At its centre
there was a small hollow. When heated before the blow-pipe, it
readily fused, and then caught fire, burning with a clear flame, and
giving out the smell of animal matter, hut nothing of a urinous
character. “ From cholesterine calculi it is readily distinguished
by the absence of any chrystalline structure when broken, which,
unless the quantity of colouring matter he very large, is always
more or less apparent in that variety ; also by its insolubility in
alcohol and aether, and by readily dissolving in these menstrua,
and in a cold solution of caustic potass, after it has beeu acted
upon by an acid.” (London and Edinburgh Phil. Magazine,
1840.)
VARIETIES.
279
There is no account of the source from which this calculus was
derived ; and it is doubtful therefore whether it was taken from
man or from one of the lower animals.
Now and then, chalky concretions, composed chiefly of carbonate
of lime, or of phosphate of lime, are found in the gall-bladder or in
the ducts, or, apparently isolated from the ducts, in the substance of
the liver. Andral relates the case of a man who died at the age of
50, in which three small calculi of phosphate of lime were found
in the gall-bladder, which contained nothing else but a little ropy
mucus. The cystic duct was obliterated. The liver was united
to all the adjacent parts by old false-membranes, and its substance
was remarkably tough and granular. The disease seems to have
commenced ten years before death, when the patient had
jaundice, which was soon followed by ascites. (Clin. Med. iv.
p. 511.)
M. Bouisson states, that he once found a calculus, of the
size of a pea, composed of carbonate of lime, projecting from the
surface of the liver. (Bouisson, p. 197.)
These chalky concretions are not formed from the bile, but
originate in disease of the mucous membrane of the gall-bladder
or ducts. In sheep that have been infested with flukes, some of
the gall- ducts not unfrequently become almost converted in this
way into bony cylinders ; and, now and then, in examining a
liver of one of these animals, we find a small chalky concretion,
apparently isolated from the ducts. These chalky bodies are sur-
rounded by a cyst, which is formed, like so many other varieties of
hepatic cyst, from a small portion of a gall-duct, which becomes
dilated by the foreign matter, and isolated, by inflammation, from
the rest of the duct.
Ordinary gall-stones are composed, as we have seen, of cho-
lesterine which, with variable proportions of colouring matter, is
deposited about a nucleus, which generally consists of biliary
matter more or less altered. The cholesterine crystallizes so as to
form rays converging from all points of the circumference of the
stone to its centre ; but, when it is mixed with, or stained by, the
colouring matters of bile, which, as is usual, are in different pro-
portions in layers successively deposited, the stone, while it still
280
GALL-STONES.
exhibits the converging rays, appears made up of distinct concentric
laminae.
Two circumstances seem, then, generally to concur in the for-
mation of these cliolesterine calculi : the presence of a small mass
of concrete biliary matter, or of some other substance, to serve as
a nucleus, and the presence of cliolesterine in crystals, to make
up the body of the stone. The first step is the formation of the
nucleus, which probably results in most cases, especially when
many gall-stones are formed together, from the peculiar prin-
ciples of the bile being in an unnatural state, and more than
usually insoluble. The second step is the formation of crystals of
cliolesterine, which, like the former, results from faulty assimila-
tion, and which is frequently associated with fatty degeneration of
the coats of the gall-bladder, if not sometimes immediately depend-
ent upon it.
In every case, the presence of a gall-stone is evidence of an un-
natural state of the bile.
The question then arises, — what conditions of life, or what other
influences, tend to bring about those unhealthy states of the bile
on which the formation of gall-stones depends ?
The first circumstance to he noticed, is, that gall -stones can seldom
he traced to structural disease in the substance of the liver itself.
Some diseases of the liver seem, indeed, to he almost incompatible
with gall-stones. Dr. Prout has made a remark, which my own expe-
rience tends to confirm, that gall-stones of cliolesterine are seldom
found in conjunction with the granular disease of the liver pro-
duced by spirit- drinking. * They are also, I believe, very seldom
met with in the diseases of the liver that occur in hot climates.
Among the numbers of bodies that I examined in the Dreadnought,
of men who returned from India with abscess or other disease of
the liver, very few, indeed hardly any, had gall-stones. It is, how-
ever, not fair to judge from these men, who were sailors, and had
probably great immunity from gall-stones, on account merely of
their sea-faring life.
The disease of the liver in which gall-stones are most frequent,
is cancer. Gall-stones are also frequently found in conjunction with
cancer of other parts. They seem connected with the cancerous
diathesis rather than with cancer of the liver itself, which probably
* I have met with one exception to this during the past year.
CAUSES.
281
gives no additional tendency to them, except when it involves the
gall-bladder, or causes the bile to stagnate in it, by narrowing the
cystic or the common duct.
The tendency to the formation of gall-stones is much influenced
by age. Gall-stones of cholesterine are seldom found in persons
under the age of 30. Bouisson, calculating from the numerous
observations collected by Walter, (Museum Anatomicum, tom iii.
in 4to. Berolini, 1805,) found that among 91 persons who had
gall-stones, 1 was 20 years of age, 27 were between 30 and 40,
14 between 40 and 50, 19 between 50 and 00, 8 between 60 and
70, 13 between 70 and 80, while 1 was 80, and another 90. The
ages of the remaining 7 are not mentioned.
The youngest person in whom 1 have, in my own dissections,
found a gall-stone of cholesterine, was a woman, eet. 24, who died
of phthisis, in King’s College Hospital, in the present summer,
(1844). In this case, there was only one gall-stone, which was
round, of the size of a small marble, and composed almost entirely
of cholesterine. The liver was extremely fatty.
Gall-stones are, in this country, much more frequent in women
than in men. My own observation agrees with that of Dr. Prout,
who says, that we sometimes see four or five cases of gall-stones
in women for one in men. Hoffman, Haller, and Soemmering,
found gall-stones more common in women than in men ; hut the
rule does not seem to he universal. Bouisson states that of the
91 instances of gall-stones collected by Walter, before referred to,
44 occurred in women, 47 in men. Morgagni states that among
the numerous cases of gall-stones he had observed himself, or had
collected from others, the number of men was nearly equal to that
of women.
The greater liability of women to gall-stones, depends, probably,
not so much on the peculiar constitution of the sex, as on their
habits of life, which are different in different countries.
Among the conditions of life that dispose to gall-stones, seden
tary occupations and confinement seem to have the greatest influ-
ence. Gall-stones have been observed to be especially frequent
among literary men, and prisoners, and people long bed-ridden ;
while, on the contrary, they are, like urinary calculi, very rare
among sailors, who lead an active and roaming life, and are con-
stantly exposed to a current of fresh air, and inspire a large quan ■
tity of oxygen. The sedentary habits of women in this country
282
GALL-STONES.
perhaps sufficiently account for their being so much more liable
to gall-stones than men.
Particular modes of living, -which directly alter the qualities of
the bile, have, without doubt, great influence in producing gall-
stones, hut our knowledge on this point is very vague. Gall-
stones are most frequent in persons of full habit, who live richly
and lead indolent lives ; but they are not unfrequently found in
persons advanced in life, especially women, who are lean and
have always been extremely temperate.
There can he no doubt also, that a liability to gall-stones often
depends on peculiarity of constitution, which, like the tendency
to gout or gravel, may he inherited, as well as acquired. At
present little is known of the characters, or of the other effects, of
this diathesis. It probably leads to fatty degeneration of the
coats of the gall-bladder, which is so frequently associated with
gall-stones ; and, perhaps, also to the fatty degeneration of the
arteries, so common in advanced life. Dr. Prout has remarked
that a tendency to the formation of gall-stones of cholesterine
is frequently associated with a tendency to lithic acid deposits
in the urine. It is probable that in London, the habit of drink-
ing porter, which frequently leads to lithic acid deposits, and to
the most inveterate forms of gout, in persons who inherit no
disposition to them, may also frequently lead to the formation of
gall-stones.
When, from any cause, the bile is prone to form deposits, vari-
ous circumstances that favour its stagnation in the gall-bladder, —
such as the habit of sleeping long, long fasting, some obstruction in
the cystic or the common duct, — that otherwise would be without
effect, may lead to the formation of gall-stones. Inflammation, or ul-
ceration, of the gall-bladder, by altering the quality of the mucus,
or by leading to the effusion of a small clot of blood, or a flake of
lymph,' may also promote the result.
When gall-stones have formed in the gall-bladder, they may
produce various effects upon the bladder and ducts. One of the
most common of these is closure of the cystic duct. A gall-stone
too large to pass through the duct, floats with the current of bile
to its mouth, and becomes firmly lodged there. This prevents the
flow of bile into the gall-bladder, and generally leads to lasting
closure, by adhesion, of the duct beyond the stone. We have al-
EFFECTS.
283
ready considered the effect which this closure of the cystic duct
has on the gall-bladder. The bile in the gall-bladder is absorbed,
and its place is occupied by the secretions of the bladder, which
consist of a raucous, glairy fluid, in which are suspended glisten-
ing scales of cliolesterine. Perhaps the closure of the duct may
lead to the formation of another gall-stone, around an unusually
large scale of cliolesterine, or a flake of lymph that may be retained
in the bladder, or some inspissated bile that may be left when the
more watery parts of the bile are absorbed. But it never happens
that many gall-stones are formed in the bladder after the cystic
duct is closed. For this, it is requisite that the bile should flow
into the bladder, and that some of its principles should be deposited
in solid masses, to serve as nuclei about which the cliolesterine
may collect.
Closure of the cystic duct of course destroys the office of the
gall-bladder, and probably by so doing deranges digestion ; but
tbe evils resulting from this are perhaps, here, more than com-
pensated by its preventing for the future the passage of gall-stones
along the ducts, which is the cause of most of the suffering, and
of many of the other evils that result from gall-stones.
If the gall-stone pass through the cystic duct, it generally passes
also through the common duct, which is larger and straigliter than
the cystic duct. If it pass slowly, and be large enough com-
pletely to block up the duct and prevent the flow of bile into the
intestine, it soon causes jaundice and dilatation of the gall-ducts
behind, and of the gall-bladder. The distension of the gall-
bladder may be so rapid, and so great, that, on some trifling
effort, as that of coughing, or of vomiting, it may burst, especially
if ite coats were previously diseased, — and its contents be poured
into the cavity of the peritoneum. Several instances of this kind
have been recorded. The gall-stone may also become fastened
in the common duct, and may lead to permanent closure of the
duct below it, by adhesion, and, consequently, to permanent
jaundice and all the other evils which obliteration of the
common duct occasions. Sometimes, a large gall-stone gets
permanently lodged in the lower end of the common duct, with-
out completely closing it. That part of the duct which embraces
the stone, participates in the dilatation of the ducts behind, and
bile still passes round the stone into the intestine. This, however,
can scarcely happen without much impeding the flow of this fluid,
284
GALLSTONES.
and leading to occasional jaundice, and, in the end, to great di-
latation of the hepatic gall-ducts, and greater or less destruction of
the secreting element of the liver. But, as before remarked, a gall-
stone seldom rests long in the common duct. After a time, which
seldom extends beyond a few days, it passes into the intestine.
One is occasionally surprised, considering the natural size of the
common duct, at the large size of a gall-stone, which has passed
through the ducts, without ulceration, into the intestine. A stone,
as large as an almond, or larger, may escape in this way. The cir-
cumstance shows to what an extent the ducts may he dilated by a
constant, and gradually increasing, fluid pressure. When the ducts
have been much dilated, they return to their natural size very
slowly. The common duct has been found as large as the finger,
or even larger, a considerable time after the passage of the stone
by which its dilatation was caused.
But gall stones, while lodged in the gall-bladder, may, by me-
chanical irritation, excite inflammation of its coats, and perhaps
hasten the progress of fatty degeneration and ossification of them.
The frequent association of gall-stones with fatty degeneration of
the coats of the gall-bladder has been already noticed. It is pro-
bable, that this change in the gall-bladder is generally the effect
of that derangement of the animal chemistry which leads to the
formation of gall-stones, and that it is often one of the immediate
causes of the gall-stones, by rendering the secretions of the gall-
bladder unhealthy, and causing them to he loaded with scales of
cholesterine ; but it is probable, also, tlmt gall-stones, once formed,
may, by mechanical irritation, bring about degeneration of the coats
of the gall-bladder, or may, in their turn, hasten that degenera-
tion of the gall-bladder to which in part they owe their origin. I
have more than once found fatty degeneration and ossification of
a gall-bladder which contained gall-stones, far more advanced than
elsewhere at its under and free surface, near the broad end, where
gall-stones must he most apt to rest.
A far more serious effect of gall-stones than simple inflamma-
tion, or fatty degeneration, of the coats of the gall-bladder, is
ulceration of the gall-bladder or ducts. The relation of gall-stones
to ulceration of the bladder and ducts has already been con-
sidered. Gall-stones are frequently associated with ulceration of
the bladder, but we must not infer, in all such cases, that the
EFFECTS.
285
ulcers were caused by the gall-stones. Ulcers of the gall-bladder
and ducts may he produced by unhealthy bile, and are sometimes
found where there are no gall-stones. It is fair, therefore, to infer,
that in some cases where gall-stones and ulcers are found toge-
ther, and where, from the ver'y existence of the gall stones, we
know that the bile has been unhealthy, the ulcers, like the gall-
stones, are the immediate effect of unhealthy bile. Small, scattered,
round ulcers found in connexion with a few small gall-stones, which
do not rest on the ulcers and can readily change their place, are pro-
bably always produced in this way. But there can be no doubt
that a large gall-stone, lodged in the bladder, or in some part of
the cystic or common duct, may cause ulceration and sloughing,
or may fret a small ulcer produced by unhealthy bile into a
large and deep one. The effects of this vary, according
to the situation of the ulcer and other circumstances. An ulcer
in the gall-bladder, or in the cystic or the common duct, may eat
through the different coats till the peritoneal coat is laid bare.
The contact of the bile then causes this to slough, and the con-
tents of the bladder or ducts escape at once into the cavity of
the peritoneum, causing inflammation of the whole surface of that
membrane, rapid collapse, and death. If, however, the cystic duct
has been previously closed, and the bile that was in the bladder
absorbed, the contents of the bladder may escape into the peri-
toneum by oozing, and suppurative inflammation may be set up,
which is limited to the neighbourhood of the gall-bladder by
adhesions, thus forming a circumscribed abscess in the cavity of
the peritoneum. But either of these events is very rare. In the
great majority of cases in which an ulcer in the gall-bladder or
ducts is formed, or fretted, by a gall-stone, adhesive inflamma-
tion of the peritoneum covering the ulcer is set up before all the
coats are eaten through, and lymph is poured out, which glues
that part of the gall-bladder or duct in which the ulcer is seated,
to the part with which it happens to be in contact. When the
ulcer is in the common duct, this is generally the duodenum ;
when in the gall-bladder, the duodenum or the colon. After
these adhesions have formed, the process of ulceration may still
go on till the coats of the bowel are eaten through as well, and
the gall-stone escapes into the intestinal canal It has been al-
ready remarked that, in such cases, the process of ulceration is
slow, and that the adhesive inflammation of the peritoneum which it
286
GALL-STONES.
sets up is of small extent, so tliat there are seldom severe or
alarming symptoms, and, now and then, the first clear intima-
tion that anything serious has been going on, is the discharge of
a large gall-stone from the bowel. A large gall-stone escaping
into the bowel in this way, may cause much less suffering than
by passing along the ducts. When an unnatural communication
is thus made between the gall-bladder, or duct, and the intestine,
the continued passage of the bile prevents it from being closed, and
a permanent biliary fistula is formed. Now and then, the gall-stone
passes by ulceration from the gall-bladder into the stomach ; or
the gall-bladder becomes adherent to the abdominal parietes,
and the gall-stone escapes, by ulceration, through them.* In
either case, unless the cystic duct be closed so as to prevent the
bile from flowing into the bladder, a permanent fistula will be
formed.
It would also seem, from cases before referred to, that gall-
stones, by causing, or by keeping up, ulceration of the gall-bladder
or ducts, may lead to abscesses in the substance of the liver ;
probably by setting up suppurative inflammation of a small vein
in the neighbourhood of the ulcer, or through absorption of
the ichorous matter of the ulcer. Such a result is, however, very
rare.
Gall-stones may exist in the bladder a long time, without
giving rise to any symptoms that are noticed. They are fre-
quently found, and sometimes in great numbers, in persons who
during life had no ailments referrible to the liver that could lead
one even to suspect them. While stationary in the bladder they
give rise to no symptoms, unless they are so large, or so nu-
merous, as to distend it, or unless there he at the same time
ulceration or inflammation of its coats. In such cases, they
cause a sense of weight or uneasiness in the region of the gall-
bladder, or pain in that part, which is felt chiefly after meals, and
which sometimes extends through to the right shoulder-blade,
or even to the right arm. The pain or uneasiness is increased by
a deep breath, or by certain movements of the body.f
* Andral Precis. d’Anat. Path. i. pp. 187 and 241.
t In describing the symptoms produced by gall-stones, I have freely
availed myself of the admirable account that has been given of them by Dr.
Prout, in the third edition of his work, on stomach and urinary diseases.
SYMPTOMS.
287
The fact that gall-stones often exist without causing pain, is
explained by the circumstance that the gall-bladder does not con-
tract on the stones, and is perhaps seldom completely emptied,
and that gall-stones are so light that they are suspended in bile,
and in consequence exert no pressure on the coats of the bladder
by reason of their weight. It may also be owing in part to the
little sensibility to pain which the gall-bladder has when not in-
flamed.
A gall-stone may also remain long impacted in the cystic duct,
without causing pain, or having other ill effect than those ob-
scure disorders of digestion which result from loss of the
bladder. Some instances of this land have been related in a
former chapter.
A gall-stone fastened in the common duct must cause jaundice
by impeding the flow of bile, but unless it occasion sloughing or
ulceration of the duct, it may cause no other pain than that which
results from the mere stoppage of the bile.
Th q passage of gall-stones through the ducts is generally pro-
ductive of great pain, but unless there be ulceration or inflamma-
tion, their mere presence, either in the bladder, or in the ducts, is
not painful.
The symptoms of the passing of gall-stones generally come on
suddenly, two or three hours after eating, with severe pain, like
that of colic, in the region of the gall-bladder, The pain is not
equable. There is a constant, dull, aching pain, which every now
and then is interrupted by a paroxysm so excruciating that the
patient bends himself double, or rolls about the floor, at the same
time pressing his hands firmly against the pit of the stomach,
which sometimes eases the pain. These severe paroxysms pro-
duce great exhaustion : the pulse becomes slow or weak, the face
pallid, and the whole body covered with a cold sweat.
Together with these symptoms, there is distressing nausea, and
frequent vomiting. The matters vomited are very acid, and, as in
all cases of repeated vomiting, while the common duct is not
closed, are bitter.
The severity of the symptoms, and the time they last, are of
course very variable, depending on tbe number, and the form, and
the size, of the stones that arc passing, and on the previous state
of the ducts. In some cases, the symptoms cease after an hour or
two, or a still shorter time, and generally, suddenly, as the stone
288
GALL-STONES.
escapes into the duodenum, — and the complaint may he taken for
mere hepatic colic. In other cases, where the stone is larger, or
the passage is less free, or where many stones pass in succession,
the symptoms may continue, with intervals of comparative ease, for
several days.
When the symptoms last lon£, the patient generally becomes
jaundiced, or sallow, and the urine deeply tinged with bile and
scanty and irritating. Now and then, in addition to nausea and
vomiting, the patient has hiccough, or a peculiar catch in drawing
breath.
Another common symptom in severe and protracted cases, is
the occurrence of rigors at irregular intervals, but sometimes after
periods almost as regular as those of ague. The rigors probably
depend on distension of the bladder or ducts. Rigors of the same
kind not unfrequently occur from distension of the urinary
bladder in consequence of stricture, or from the introduction of a
catheter, and now and then from distension of the large intestine
by faeces.
The passing of gall-stones does not produce, at first, either ten-
derness of the side, or fever. On the contrary, the pain is gene-
rally somewhat eased by firm pressure, and during the severe
paroxysms of pain, the skin is cold, and the pulse slow or weak.
If, however, the stone be long in passing, some degree of fever is
set up, the epigastrium becomes tender, and the tongue foul.
These symptoms are probably owing to inflammation of the ducts
caused hy the mechanical irritation of the stone. Besides tender-
ness at the epigastrium, there is general soreness of the belly, from
the repeated efforts of vomiting, and from the spasmodic action of
the muscles during the paroxysms of pain.
The passage of a gall-stone through the ducts, though produc-
tive of alarming symptoms, is attended with little immediate
danger to life. It can only prove fatal when the stone gets long
fastened in the common duct, but, as before remarked, the common
duct is larger and straighter than the cystic duct, so that a stone
which has passed through the cystic duct, generally passes through
the common duct as well. The stone, after having caused the
most agonizing pain, (continued perhaps with short intervals of
comparative ease for several days), and great exhaustion, and
jaundice, passes into the intestine, and the alarming symptoms at
once cease. But it now and then happens, that a person dies
SYMPTOMS.
289
from a gall-stone sticking in the common duct. An instance of
this is recorded by Abercrombie.
Case. — A lady, aged 60, had been for several years liable to attacks of
acute pain in the right hypochondriac region, which generally continued very
severe for a few hours, and then subsided suddenly. On the 14th of Ja-
nuary, 1824, she was seized with pain as in her former attacks, but which did
not subside as usual. It continued through the night, accompanied by fre-
quent vomiting, and constitutional disturbance. On the 15th, there was
fever, with frequent vomiting and obstinate costiveness, and the pain was
more extended, — being referred to a considerable space on the right side of
the abdomen. Belly tense and rather tumid. The case had assumed the
characters of ileus, and all the usual means were employed with little relief.
On the 16th, there was some discharge from the bowels, after a tobacco
injection, but it was very scanty. Severe pain continued, with every expres-
sion of intense suffering. Her strength sunk, and she died on the morning
of the 17th.
Inspection. — Every part of the intestinal canal was perfectly healthy, except
the upper part of the duodenum, where there was considerable appearance of
inflammation, with remarkable softening, so that it was very easily torn. A
large irregular calculus was found sticking in the ductus communis, and the
parts were so softened that it came through the side of the duct when it was
very slightly handled. In the texture behind the duodenum, there was con-
siderable appearance of inflammation. No morbid appearance was detected
in any other organ. (Diseases of Stomach, &c., 2nd ed. p. 389.)
Several instances of tbe same kind bave been published by other
writers. Instances are also recorded where a gall-stone in tbe
common duct has proved speedily fatal, by causing bursting of tbe
gall-bladder, or of tbe duct behind, in consequence of their great
and rapid distension. But when a gall-stone in the common duct
proves fatal, it is generally by causing obhteration of tbe duct,
and lasting jaundice. A fatal event, in any way, is, however, ex-
tremely rare. In tbe great majority of instances, tbe stone passes
into tbe intestine, and tbe chief danger is over.
If tbe time of its passing has been short, the patient is then
well, or suffers merely from tbe exhaustion consequent on the severe
pain and tbe repeated efforts of vomiting, and from the irritation
and obstruction which tbe stone may afterwards occasion in its
passage through tbe bowel. But if tbe stone have been long in
passing, and bave produced jaundice, tbe patient, after it escapes
into tbe duodenum, has tbe tenderness and tbe fever consequent
on tbe injury done to the ducts, and tbe additional disorder caused
by long pent-up and irritating bile flowing suddenly into tbe in
testine. u
2Q0
GALL-STONES.
Gall-stones in their passage through the intestine frequently
produce slight colic and tenesmus, but seldom other evils unless
they are very large. When this is the case, they may obstruct the
bowel and cause constipation, or even fatal ileus. Many instances
of this hind are recorded.*
But a small gall-stone, like any other small hard body, may, in
its passage through the intestine, get lodged in the vermiform ap-
pendix, and may cause ulceration, or sloughing, and perforation, of
the appendix ; and, as a consequence of this, a circumscribed ab-
scess in the cavity of the peritoneum, or general peritonitis that proves
rapidly fatal, — according as the contents of the intestine ooze into
the cavity of the peritoneum, or are poured into it at once. Seve-
ral instances of this kind have been recorded, and one such has
fallen under my own notice. Such events are, however, very
rare, and, in general, the passage of a gall-stone through the in-
testine causes no other inconvenience than a little colic and
tenesmus.
The symptoms hitherto mentioned, result merely from the
mechanical effects of the stones, in the gall-bladder, or in their
passage through the gall- ducts and the bowel. But persons who
have gall-stones have frequently other ailments, which result from
the faulty assimilation that led to the gall-stones, and perhaps
in part from the irritation of the stones, even when they do not
cause the severer symptoms that mark their passage. These ail-
ments are usually of a very vague and uncertain character. In
one person, they are principally nervous, and consist in hypo-
chondriasis, or depression of spirits, or other nervous disorder ; in
another, they are chiefly disorders of digestion that are complained
of; in a third, the urine is unhealthy, and frequently deposits
litliic gravel, and the chief complaint is of irritation of the kidneys
or of the bladder. Persons of middle age, or older, who have
urinary calculus, have not unfrequently gall-stones as well. Nu-
merous examples of this were collected by Morgagni, who inferred
from them that the causes of gall-stones are in great part the same
as those of urinary calculi ; and that the presence of a urinary
calculus, in a person of middle age or older, should strengthen any
* A case of this kind is published by Abercrombie (2nd ed. p. 133), and one
by Cruveilhier, (liv. xii. pi. 4,p. 3) : and two others are referred to in an ela-
borate paper on gall-stones, by M. Fauconneau Dufresne, published in the
first volume of the Revue Medicale, for 1841 (p. 194).
SYMPTOMS.
291
suspicions of the existence of gall-stones, -which other symptoms
may awaken. (Epist. xxxvii. art. 43 )
Many of the various ailments that are found associated with
gall-stones, are, no doubt, mainly owing to the faulty assi-
milation in -which these originate, but it would seem that in
some cases they are attributable in great part to the mere
irritation kept up by the gall-stones themselves. Dr. Prout
says, “ I have seen several instances of biliary concretion, in
which the urinary derangements have become so prominent as
to exclude the other symptoms ; so that the true nature of the
disease has been overlooked. Thus, many years ago, I attended
a patient for a supposed urinary affection, which disappeared
after an attack of gall-stones, the existence of which had
not been suspected. In this case, the urine was copious, almost
limpid, and constantly serous ; there was considerable irritation of
the bladder, particularly towards the morning ; a dull, uneasy
sensation was also felt about the region of the kidneys, and the
functions of the stomach and bowels were much disturbed. All
these and other symptoms, however apparently indicating renal
affection, to my surprise, either left or ceased to trouble the patient
after a severe attack of jaundice, accompanied by tbe passage of
gall-stones. In this case, a great tendency to disease, if not
actual incipient disease of the kidneys, was excited, or perhaps
produced, by a remote mechanical irritant. Nor can there be any
reason to doubt, that if this exciting cause had not been removed,
the disease of the kidneys would have become confirmed, and
taken its usual course. I am unable to state whether the urine
entirely recovered its healthy condition, or having recovered its
healthy condition, whether it still retains such condition ; but the
patient is alive, and apparently well.” (Stomach and Urinary
Diseases, 3rd ed. p. 253.)
A person who has once suffered from the passing of a gall-
stone, is very liable to suffer in the same way again. Where there
are many gall-stones in the bladder, a few only, or even a single
one, may pass at a time ; or after all that were in the bladder have
come away, others may form in their place. Now and then, a
person after having suffered from the passing of gall-stones at
irregular intervals for years, has freedom from such suffering for
the rest of his life. This may happen from the cystic duct becoming
u 2
292
GALL-STONES.
blocked up by a stone ; an event, which allows no others to form, or,
at any rate, to pass ; or it may happen from all the stones in the
bladder being at length discharged, and no others forming in their
place. It has been already remarked, that when there are many gall-
stones in a bladder, they have usually the same characters, and
appear to have been formed at the same time. The immediate
cause of their formation is probably the deposit of some of the
principles of the bile in solid form, in consequence of some
passing fault of the bile, or of unusual retention, which may not
again occur.
From the account that has been given of the symptoms pro-
duced by gall-stones, it will appear, that before any have passed,
while they are still lodged in the bladder, or when one has be-
come impacted in the cystic duct, it is impossible to detect them.
They then give rise to no symptoms, or merely to some pain or
uneasiness in the region of the gall-bladder, with certain obscure
derangements of health, which may equally result from ulcera-
tion of the gall-bladder, from organic disease of the liver itself,
from disorder of the stomach or of the large intestine, and from
various other causes. No constant, or peculiar constitutional
symptoms, indicative of gall-stones, have been yet noticed, and
our knowledge of the circumstances under which gall-stones
occur, is too meagre to give meaning to symptoms otherwise
vague.
When gall-stones are passing, the symptoms are more signi-
ficant, but even then are seldom so peculiar as to give assurance
of the fact, unless the person have had former attacks of the
same kind, and have ascertained that they resulted from gall-
stones. Sometimes, indeed, the passing of gall-stones causes but
a few severe paroxysms of pain, or a few sharp twinges, which,
unless it be known that the person has passed gall-stones before,
are usually set down as hepatic colic. Now and then acute pain
in the region of the liver, which is more severe in paroxysms, and is
unattended by fever, occurs without gall-stones, or any disease that
we can discover in the liver, or in its ducts. The pain seems to be
purely nervous, and may be conveniently designated, hepatic colic.
Knowledge of the causes of such attacks, or at least of the circum-
stances in which they occur, would help us very much in the de-
tection of gall-stones. Like other nervous affections, these attacks
DIAGNOSIS.
293
are most common in unmarried, or hysterical, women, and in such
persons there are usually several circumstances that enable us to
distinguish them from the paroxysms of pain produced by the
passing of gall-stones. They have been preceded by hysterical
pain, or spasm, in other parts of the body ; or the paroxysms are
brought on by emotion, or fatigue ; and, as in other painful hyste-
rical disorders, there is exquisite and widely diffused tenderness.
The symptoms produced by the passage of gall-stones are very
like those produced by a calculus in the pelvis of the kidney, or
in the ureter, and when there is no jaundice, the one disease may
be easily mistaken for the other. When jaundice succeeds to the
other symptoms, there is much less chance of error. It is then
clear that there is disease of the liver, and that either the secretion
of bile, or its passage into the duodenum, is stopped. Where the
illness begins suddenly with pain in the region of the gall-bladder,
which has excruciating paroxysms, attended with vomiting, but at
first, without tenderness, and without fever, and where this is fol-
lowed, at the end of a day or two, by jaundice ; where, moreover,
the person is of sedentary habits, and of middle age or older, —
the condition of life and the age in which gall-stones are common,
— there can be but little doubt that the illness is owing to the
passage of gall-stones. The presumption that such is the case is
still stronger, if the person have had similar attacks before, and if
in these the violent symptoms have ceased, as they began, sud-
denly. Such a succession of events is almost proof of the passage
of gall-stones. They can hardly occur from any other condition.
It frequently happens, however, that the symptoms are of more
doubtful character. A large stone may escape into the bowel by
ulceration, or even through the ducts, without much pain, and in
a first attack, the patient cannot tell what is happening from his
former experience, and the evidence furnished by the mere repeti-
tion of similar attacks is of course wanting. On all these
accounts, it often happens that we can only guess that gall-
stones are passing. In all cases where the illness is suspected
to result from gall-stones, the matters discharged from the bowels
should be examined with the view to discover the stones. It
is always satisfactory to see the stones ; and we may, besides,
draw important inferences from their size and form. If only
one stone is discovered, and this is of considerable size, and
•294
GALL-STONES.
round, or oval, we may infer that there are no others in the
bladder, and that if the patient change his mode of life, he
may not suffer in the same way again. If the stone be of con-
siderable size, but instead of being round or oval, have smooth
or polished faces, we may be sure that there were others,
but probably not many, in the bladder with it, and which
perhaps are still there. If the stone be small, with faces, or even
if many such stones are found, the probability is still greater
that more are yet left in the bladder which will pass out, and the
patient may expect at uncertain intervals a recurrence of similar
attacks. Dr. Prout says, that when the passage of gall-stones is
suspected, directions should be given to mix the faeces with water,
on the surface of which the stones, if present, will be found
floating. But this certainly will not always happen. Most gall-
stones, when fresh from the bladder, are heavier than water. They
become indeed lighter than water by drying, and will then float in
water until they have imbibed a certain quantity of it, when they
sink slowly to the bottom.
Dr. Watson has also recommended the adoption of this method
of finding the stones, but he adds, “ I never but once succeeded
in thus catching a concretion in the evacuations of a patient, whose
symptoms had led me to search for it.” (Lectures on the Prac-
tice of Physic, vol. ii. p. 527.)
In the treatme?it of gall-stones, three distinct objects have been
proposed: — 1st, To calm the pain and spasm, while the stone is
passing ; 2nd, To dissolve any stones that may remain in the
bladder ; 3rd, To prevent fresh stones from forming.
While a gall-stone is passing, nothing calms pain and spasm,
and prevents, therefore, the exhaustion they occasion, so much as
opium. This should be given in large doses, and is generally best
given as a pill ; for, from the irritability of the stomach, liquids
are usually almost immediately rejected. Occasionally, opium
may be given with advantage in effervescing draughts, or with
hydrocyanic acid, which allays the irritability of the stomach, and
for a time enables the patient to retain it. In some cases, much
relief is obtained from sulphuric aether, in conjunction with opium.
But, according to Dr. Prout, more immediate relief is often af-
forded by large draughts of hot water, containing carbonate of
soda in solution, (in proportion of from one to two drachms of
TREATMENT.
295
the carbonate to a pint of water,) than by any other means.
“ The alkali counteracts tire distressing symptoms produced by
the acidity of the stomach ; while the hot water acts like a fomenta-
tion to the seat of the pain. The first portions of water are com-
monly rejected almost immediately; hut others may be repeatedly
taken ; and after some time, it will be usually found that the pain
will become less, and the water be retained. Another advantage
of this plan of treatment is, that the water abates the severity of
the retching ; which is usually most severe and dangerous, where
there is nothing present on which the stomach can react. This
plan does not supersede the use of opium, which may be given in
any way deemed most desirable ; and in some instances, a few
drops of laudanum may be advantageously conjoined with the
alkaline solution, after it has been once or twice rejected.”
(Third ed. p. 263.)
Fomentation of hot water, alone or with opium, or decoction of
poppies, or other appliances of the same kind, or the warm bath,
should be had recourse to at the same time, and will often much
alleviate the patient’s sufferings. If these means fail, we may try
very cold applications — as a bladder of pounded ice — which have
been much recommended by several writers, and it would seem,
have often been productive of benefit.
It seems to have been formerly the practice to give emetics or
strong purgatives, to quicken the passage of the stone ; but this
practice has been justly reprobated on the ground that it increases
the pain before the ducts are sufficiently dilated to allow the stone
to pass. A certain time is requisite for the necessary dilatation of
the ducts ; and when the stone is in the common duct it is suffi-
ciently urged forward by the constant and gradually increasing
pressure of the accumulated bile behind.
When the symptoms lead to the inference, that the stone has
passed into the duodenum, purgatives and copious injections of
warm water should be given to hasten its discharge from the
bowel, and with it the discharge of the accumulated and irritating
bile.
If any tenderness and fever should come on during the passage
of the stone, leeches should be applied at once to the tender part.
These symptoms show that inflammation of the ducts has been set
up, which may produce ill effects of various kinds. Wc have con-
sidered in a former chapter the nature of these effects, and the
296
GALL-STONES.
great importance of early applying local remedies — leeches and
blisters — when the symptoms lead to the inference that inflamma-
tion either of the gall-bladder, or of the ducts, exists. In the pre-
sent instance, the tenderness and the fever, from the peculiar symp-
toms that precede them, are unusually significant of inflammation
of the ducts, and of inflammation excited by a local cause, and
therefore to be chiefly relieved by local remedies.
The second object proposed in the treatment of gall-stones, is
to endeavour by medicines to dissolve any stones that may yet
remain in the bladder. Various medicines have at different times
had the credit of doing this. The alkaline carbonates were long held
in repute as solvents of gall-stones, and a plausible reason of their
having such virtues has been assigned in the great solubility of the
cliolesterates of potash and soda. Soda is a natural constituent of
bile. It is probable, therefore, that salts of soda, given as medi-
cine, may be in part excreted in the bile, and may tend to form a
soluble compound of cholesterine.
But the medicine that has been most celebrated as a solvent for
gall-stones, is a combination of sulphuric tether and turpentine.
This was at one time much relied on in France, where it was
brought into great vogue by Durande, a physician of Dijon,
who published the details of many cases for the sake of establish-
ing its efficacy. Durande’s remedy, which consisted of a mixture
of three parts of aether with two of essence of turpentine, became
in consequence very famous. It has never been much employed
in this country, and latterly has lost much of the credit it at one
time had in France.
It is clear that it must be extremely difficult to obtain satis-
factory evidence in favour of such virtue for any medicine. Before
gall-stones have passed we can never be sure of their existence ;
and after a person has once passed gall-stones, he may go on for
years, or even for the rest of his life, without passing others. All
the stones in the bladder may have come away at once, and no
others may form ; or those which remain in the bladder may be
too large to pass out ; or one may have permanently blocked up
the cystic duot : or, if the person continue to pass gall-stones, he
may suffer much less in the subsequent attacks than at first,
on account of the dilatation of the ducts which was then effected,
or the smaller size of the stones. When, therefore, a person who
has once passed gall-stones, passes no more for the future, or
TREATMENT.
297
if he lmve other attacks, suffers less in them than in the first, we
must be very cautious in assuming that this happy circumstance is
the effect of our remedies.
Medicines whose efficacy is so difficult to establish, however real
this efficacy may be, almost inevitably fall after a time into disre-
pute. This has happened for taraxacum and for most other medi-
cines that have been supposed to increase the quantity and to alter
the qualities of the bile. Few have the same faith in the reputed
virtues of cholagoguea and alteratives of the bile, as they have in
medicines which increase the quantity or alter the qualities of the
urine, because, although analogy leads us to conclude that some
medicines have such virtues, we have not the same proof that the
virtues actually belong to the particular medicines to which they
have been ascribed. The natural tendency, therefore, seems to be
to estimate too low the value of such medicines, and perhaps we
have, of late, too much discarded the notion, that gall-stones, once
formed in the bladder, may be again dissolved. Combinations of
sether and turpentine, if they do not dissolve gall-stones, seem
occasionally to have done good, — probably by relieving the pain
and spasm which the irritation of gall-stones occasions.
The third object of treatment, is, when gall-stones have been
formed and passed, to prevent others from forming in future. For
this, we must chiefly rely on exercise and proper diet. The
patient should rise early, take plenty of exercise, on foot, or on
horseback ; and abstain as much as possible from fat, or gross
meats, and heavy malt liquors. The bowels should be duly regu-
lated, if need be, by the habitual use of rhubarb, or rhubarb and
aloes; or by mild saline purgatives, as the P'ulna water; and
the action of the skin should be kept up by an occasional warm
bath.
In addition to these means, we may endeavour to render the
bile more healthy by some of those medicines, which are supposed
to alter its quality. In some persons who suffer from gall-stones,
and other disorders that result from an unhealthy state of the bile,
no medicine does such signal good as small doses of mercury con-
tinued for some time. They seem to increase the quantity of the
bile, and at the same time to render it more healthy, and they
certainly often improve in a striking manner the general health.
The best preparation of mercury for this purpose is the blue pill.
It may be given most safely, and with best chance of benefit, in
298
GALL-STONES.
persons of full habit, who have lived freely, and in whom there is
no reason to suspect organic disease.
Where the patient is thin, or has lived badly, or where there is
reason to fear organic disease of the liver, or of some other organ, it
is safer and wiser to abstain from mercury, and to be content with
taraxacum, or muriate of ammonia, or the alkaline carbonates, or
other mild medicines that are supposed to alter the qualities of
the bile. Where the secretion of bile has been long disordered,
and the health is mucli broken, great benefit sometimes results
from a mild course of the natural alkaline or saline waters. The
alkaline waters of Vichy and Ems, and the waters of Carlsbad, on
the continent ; and in tins country, the saline waters of Chelten-
ham and Leamington, and the sulphurous waters of Harrowgate,
are those whose efficacy in such cases is best established. The
waters of Vichy, in particular, are very highly thought of by
French physicians, and probably with sufficient reason.
299
CHAPTER IV.
DISEASES WHICH RESULT FROM SOME GROWTH FOREIGN TO
THE NATURAL STRUCTURE.
Sect. I. — Cancer of the liver — Origin of cancerous tumors of
the liver — Their growth, dissemination , and effects — Encysted ,
knotty tubcra of the liver.
Having considered the inflammatory diseases of the liver, and
the diseases which result from impaired nutrition of its tissues,
and from faulty secretion, there remain for us to consider those
which consist in some growth foreign to the natural structure.
The most important member of this class is cancer , which is
more frequent in the liver than in any other organ. Indeed, no
serious organic disease of the liver is, in this country, — at least
among people who have never drunk hard, — so frequent as cancer.
In some instances, the liver is the only organ infected with
cancer, or is the organ in which the cancer originates ; but far
oftener, the formation of cancerous tumors in it is consequent
on cancer of some other part, especially the stomach and the
breast.
In the Anatomie Pathologique of Cruveilhier, the Clinique
Medicale of Andral, and the little work by Dr. Farre on the Morbid
Anatomy of the Liver , twenty-nine cases are recorded in which
cancerous tumors were found in the liver. In three only of these
cases, was the disease confined to the liver, (Cruv. liv. xii. pi. 2, p. 8 ;
Clin. Med. iv. p. 445 ; Farre, case 2.) In another case, (Cruv.
liv. xxxvii. pi. 4, p. 3,) the lungs and the liver were the only
300
CANCER OF THE LIVER.
organs in which cancerous tumors were noticed ; in another, (Clin.
Med. iv. 433), the liver and the gastro-hepatic omentum. In all
these cases, it is, perhaps, fair to conclude that the disease origi-
nated in the liver.
In the remaining twenty-four cases, other parts of the body
were affected with cancer, as well as the liver. In thirteen of
them, there was cancer of the stomach ; in five, cancer of the
breast. Some particulars of these cases will be presently men-
tioned, which leave little doubt, that in most of them, if not in all,
the disease was propagated to the liver from the stomach and the
breast, respectively.
Many circumstances conspire to render the liver more frequently
than any other organ, the seat of both disseminated abscesses and
disseminated cancer.
The great vascularity of the liver, and the slowness with which
the blood, already retarded by passing through a system of capil-
lary vessels, traverses the dense plexus of vessels that goes to form
its lobular substance, unquestionably favour this result. But a
circumstance much more influential is — that the liver is the organ
through which the blood returning from the intestinal canal first
passes. When the stomach or intestines are ulcerated, the blood
that flows to the liver from these parts is liable to be contaminated
by pus, and other noxious matters, which cause inflammation that
rapidly passes on to abscess. When the stomach is the seat of
cancer, the portal blood is Table to be contaminated by cancer-
germs, which being stopped in their passage through the liver, are
there developed into cancerous tumors. In such cases, the ab-
scesses and the secondary cancerous tumors are usually found
only in the liver, which seems to detain all the pus-globules and
cancer-germs that are brought to it by the portal blood. It rarely
happens that any of these seeds of mischief pass through to cause
abscesses, or cancerous tumors, in the lungs and other organs.
It is seldom that a single cancerous growth is found in the liver.
There are usually scattered through its substance a great number,
often hundreds, of round tumors, some of them so small as to be
distinguished with difficulty, others of the size of a bean, of a wal-
nut, or of an orange. Sometimes, indeed, they grow still larger,
especially when there are but few of them ; for, as Cruveilhier has
justly remarked, the size of cancerous tumors in the liver is
usually inversely as their number.
CANCER OF TIIE LIVER.
301
When they are numerous, it is generally plain from their differ-
ence of size and texture, that they are of different ages — so that
in the same liver they are often seen in various stages of growth.
The first token of the deposit of cancerous matter, discoverable
by the naked eye, is a change of colour which is limited to two or
three contiguous lobules, or even to a single lobule. The tainted
lobules, instead of being of their natural tint, are whitish or black,
according to the variety of cancer, and are altered in consistence,
but they remain unchanged in size and form ; — thus, showing that
the disease originates in the lobules, and not in the areolar tissue
in the small portal canals.
Not unfrequently, in a small cancerous tumor, throughout,
and near the circumference in large tumors, when they are cut
across, a mottled appearance is seen, like that of the lobular struc-
ture of the liver, and clearly resulting from this structure having
been involved in the cancerous growth.
But if the disease originates in the lobules, and for a time con-
tinues to invade contiguous lobules in its growth, the tumor
becomes at length independent of the lobular substance, which in
its further growth it pushes aside, and compresses. Large tumors
are usually connected with the substance of the liver in which
they are imbedded, only by means of areolar tissue and vessels ;
and, when sufficiently firm, can often be readily peeled out. They
are seldom surrounded by a capsule or cyst ; and the hepatic tissue
about them usually presents no other changes than those pro-
duced by pressure.
One effect of pressure not unfrequently observed when the
cancerous tumors are thickly studded, is partial biliary con-
gestion. Portions of the hepatic substance between the tumors
are of a dark green, or an olive colour, in consequence of com-
pression of the small gall-ducts. The cancer may afterwards in-
vade these portions, and the corresponding parts of the cancerous
growth will be deeply coloured with bile. I have more than once
found parts near the circumference of large cancerous tumors,
and small cancerous tumors throughout, tinged of a deep green,
— evidently from the cancer having invaded portions of the hepa-
tic substance already congested with bile.
The hepatic substance immediately surrounding a cancerous
tumor not unfrequently, however, exhibits a change which can-
not, perhaps, be attributed to pressure. It is pale and fatty,
302
CANCER OF THE LIVER.
•while other portions are not so. As before remarked, this partial
deposit of fat around cancer is not peculiar to the liver, but is
often found, also, in cancer of the omentum and of other parts.
Those cancerous tumors which originate near the surface of the
liver, in growing project above it, so as to render it knotty or uneven.
When the projecting tumors are large, the centre of the project-
ing portion is often somewhat depressed or cupped ; an effect, it
would seem, of strangulation of the central part of the tumor.
The tumor is more freely supplied with blood, and grows faster,
round the edge. This cupped form is not peculiar to cancerous
tumors of the liver, hut is sometimes observed also, though
much less frequently, in cancerous tumors of the lung, when
these are large and project above the general surface of the
pleura.
Cancerous tumors in the liver, as in other parts, differ much
in firmness, vascularity, and colour, in different cases. Some-
times, the tumors are white and fibrous, or, as it is termed,
scirrhous; hut far more frequently, especially when numerous,
they are soft, or medullary . Instances are now and then met with,
in which, in the same liver, some tumors are hard, and others
soft.
Soft cancer presents the same varieties in the liver, as in other
organs. Most commonly the cancerous mass contains hut few
vessels, and is pulpy and whitish, or of a greyish-white — present-
ing that striking resemblance to brain rather softened, which led
Laennec to apply to it the term, encephaloid. In other cases, the
tumors are extremely vascular, presenting the appearance known
as fungus hematodes. In others, again, they are melanotic. In-
deed, every variety of cancer, except gelatiniform, or colloid
cancer, has been met with in this organ.
The colour of melanotic tumors of the liver varies, according
to the quantity of pigment granules which they contain. In the
same liver tumors may sometimes be found of every shade from
light brown to black.
Melanosis, whatever he its primary seat, becomes disseminated
sooner, and more widely, than any other variety of cancer. I am
not aware that melanotic tumors have ever been found in the
liver only ; and when they exist in the liver, they are usually in
very great number. Sometimes, indeed, the whole liver is thickly
VARIETIES.
303
studded with small black grains, giving to a section of it an ap-
pearance compared by Cruveilhier to granite, or black mica. *
Large cancerous tumors, whether bard or soft, white or mela-
notic, are usually slightly lobulated, from there having been
greater impediment to their growth in some directions than in
others ; and, as before remarked, are united to the substance of
the liver in which they are imbedded, only by areolar tissue and
vessels. It happens, however, now and then, though very seldom,
that tumors of medullary cancer are surrounded by a well-defined
cyst. The cyst, as was observed by Laennec, is a smooth mem-
brane, about half a line in thickness, of fibrous texture, and silvery
white colour, imperfectly transparent, and easily separable from
the mass it encloses.
Encysted cancerous tumors are always very soft and fluctuat-
ing, having much the feel of an abscess. When cut across and
macerated, the pulpy matter is washed out, and a beautiful fila-
mentous mass is left. We are ignorant of the circumstances
winch determine the formation of the cyst. Melanotic tumors,
as well as common encephaloid tumors, are sometimes encysted ;
and some tumors in a liver may be encysted, while others are
not. (Cruv. liv. xxiii. pi. 5, p. 5.) It may be, that the cyst is
owing to the development of cancerous matter from the inner sur-
face of a gall-duct. The cyst is very like that of the knotty tu-
mors containing a cheese-like matter which are sometimes found
in the liver, and which (as will be seen towards the end of this
chapter), appear to originate in inflammation of a small gall-duct.
It now and then happens that cancer is found in the gall-
bladder, as well as in the substance of the liver. Sometimes, the
cancer of the gall-bladder is distinct from the neighbouring
cancerous masses; in other cases, it results from a cancerous
tumor in the substance of the liver involving the gall-bladder in
its growth.
Not unfrequently, too, cancerous matter may be found in the
veins of the fiver, and, as happens for the gall-bladder, this may
grow from their inner surface, and be distinct from the neighbour-
ing cancerous masses, or it may result from a cancerous tumor
involving, and penetrating, as it grows, the coats of the vein from
without.
* There is a beautiful preparation showing this in the Museum of King’s
College. (Prep. 324.)
304
CANCER OF THE LIVER.
When a liver contains numerous masses of cancer, it is gene-
rally much enlarged, extending far below the false ribs, aud
sometimes even to the brim of the pelvis. Its increased size is
in most cases owing entirely to the presence of the cancerous
tumours ; and, indeed, when these are removed, the hepatic sub-
stance is found to he diminished in volume. As before remarked,
portions of the lobular substance are involved in the tumors;
and other portions, especially between contiguous cancerous
masses, are sometimes found pale and atrophied, and even con-
verted into fibrous tissue — probably, from their supply of blood
being stopped by the pressure of the cancerous masses, or by can-
cerous matter within the veins, or by adhesive inflammation of the
inner surface of the veins, which is very common in the neigh-
bourhood of cancer in some other parts.
From the tumors thus invading the lobular substance of the
fiver in their growth, and from their causing atrophy of other
portions, the organ may contain numerous masses of cancer, and
yet be smaller than in health.
But this happens very seldom. In almost all cases, the tu-
mors more than compensate in bulk for any destruction or
wasting of the lobular substance which they occasion ; and some-
times the bulk of the organ, without the tumors, is much in-
creased from the presence of an unusual quantity of fatty matter,
or other elements of secretion, in the hepatic cells.
Even when the cancerous masses have grown rapidly, there are
seldom any marks of inflammation in the hepatic tissue around
them. The tumors owe their development, not to any process of
inflammation, but to their own independent vitality ; and the he •
patic tissue in which they are lodged generally presents no other
changes of structure than those produced by pressure and defective
nutrition.
But although cancerous growths do not cause inflammation of
the surrounding hepatic tissue, they now and then, when superfi-
cial, cause inflammation of the peritoneum above them. But even
this happens seldom. The fiver is often found much enlarged
from cancerous tumors, and much deformed by some of these
tumors projecting above its surface, without any traces of
inflammation of its capsule. When inflammation occurs, it is
probably caused by rupture of the peritoneal coat aud escape
of cancerous matter.
EFFECTS.
3or»
The character of the peritoneal inflammation which is excited
by cancer has been already noticed. It is always adhesive, and is
generally very partial, causing the effusion of only a very small
quantity of fibrine. The usual traces of it found after death, are
opacity and apparent thickening of the peritoneum above the pro-
jecting tumors, or very delicate, threadlike bands, uniting these
tumors to the opposite surface of the diaphragm or abdominal
walls. Sometimes, however, the inflammation is more extensive,
and it may involve the entire surface of the liver, and even that
of the. peritoneum.
But it is a property of cancer to invade and destroy all struc-
tures within its immediate reach ; and in consequence of this, if a
cancerous mass be on the convex surface of the liver, it may eat
tln-ough the diaphragm, and cause adhesive inflammation of the
pleura. (Cruv., Liv. xxxvii. pi. 4, p. 4.)
Cancer of the liver, may, perhaps, also, like cancer of other parts,
cause adhesive inflammation of contiguous veins. Inflammation
of the adjacent veins is very common in cancer of the uterus, and
it is in such cases that the inflammation of veins which is produced
by cancer has been most studied. The uterine, and often one or
both of the iliac veins, are found blocked up with fibrine. Lower
down in the veins, proceeding against the course of the circula-
tion, there may be small collections of pus, bounded above and
below by fibrine ; and sometimes the veins of the leg for a great
length are found filled with pus. I met with an instance of this,
in the spring of 1843, in a poor woman, who died, under my care,
in King’s College Hospital.
She had cancer of the neck of the uterus, which had eaten into the bladder,
in front, and into the rectum, behind, so that, for many weeks before her
death, both the urine and the faeces were continually passing through the
vagina. She had constant severe pain in the lower part of the belly, and
occasional pain in the region of the liver. Two or three weeks before her
death, she began to complain of severe pain in both legs, which became very
much swelled.
The intestines in the lower part of the abdomen were found matted toge-
ther, while those in the upper part were free, and presented no traces of in-
flammation. On separating the adherent coils, two pouches of the perito-
neum filled with pus were opened.
The lumbar glands were cancerous, aud the liver was studded with medul-
lary tumors, of various sizes, many of the superficial of which were united
to the opposite surface of the diaphragm, or abdominal walls, by threadlike
x
30(5
CANCER OF THE LIVER.
bands of false membrane. In the lower lobe of the left lung, was a small
whitish mass which was inferred to be cancer. No cancerous tumors were
discovered in other parts of the body.
The internal iliac vein on each side was blocked up with fibrine, while the
femoral and popliteal veins, and the veins of the legs as far as they were
traced, were filled with pus. The left knee joint contained a large quantity
of pus, but there was none in any other joint, nor were there any abscesses
in other parts of the body. The fibrine that plugged the upper portion of
the vein prevented the pus from contaminating the circulating blood.
Cruveilkier lias distinctly remarked, that while it is very com-
mon in cancer of the uterus, for small isolated collections of pus
to form in the veins of the pelvis or of the legs, it very seldom
happens that abscesses form in other parts of the body, or that the
patient presents the general symptoms of contamination of the
blood by pus. The pus is prevented from mixing with the cir-
culating blood by adhesive inflammation of the upper portion of
the vein. It would seem, that adhesive inflammation is first set
up in this portion, and that, afterwards, suppurative inflammation
is excited in the portion below. This sometimes happens in in-
flammation of veins from other causes ; and it would almost
seem, that adhesive inflammation of the trunk of a vein may,
of itself, cause suppurative inflammation of the branches through
which the flow of blood is thus prevented.
In cancer of the liver, I have more than once found some veins
of this organ blocked up with what I took for fibrine ; but have
never found any filled with pus. Inflammation of the contiguous
veins is most common in cancer of the uterus and cancer of the
breast — in consequence of the great frequency of ulceration in
cancer of those parts. The ulceration produced by cancer, like
that from other causes, is adequate, of itself, to cause inflam-
mation of adjacent veins.
It not unffequently happens that, with cancer of the liver, a
collection of serous fluid is found in the cavity of the peritoneum,
even when this membrane presents no trace of inflammation. The
serum is probably effused in consequence of obstruction to the
passage of blood through part of the liver, from some of the veins
being blocked up by cancerous matter, or by fibrine, or simply
compressed by the cancerous tumors.* The quantity of fluid in
* In a preparation in the Museum of King’s College (No. 288), large
branches of the hepatic vein between contiguous masses of cancer are seen
to be flattened.
DISSEMINATION OF CANCER.
307
the peritoneum in such cases is usually small ; and is very seldom
sufficient to cause the distension of the belly which is observed in
cirrhosis, where the passage of blood through every part of the
liver is impeded.
A similar effect is frequently produced by cancerous masses in
the lung. Serous fluid collects in the cavity of the pleura, with-
out any inflammation of the serous membrane, or, at any rate,
without inflammation that leaves other permanent traces.
But there may be impediment to the flow of blood and partial
oedema, in the cancerous mass itself. The centre of a large can-
cerous tumor in the liver has not unfrequently a gelatinous
appearance, and when this part is punctured, and the tumor
pressed, a transparent, serous fluid escapes, very unlike the opaque
white fluid of cancer. This oedema is very common in the pro-
jecting tumors whose surface is cup-shaped.
Another occasional event in the soft and vascular varieties of
cancer of the liver, is hemorrhage into the cancerous mass. This
sometimes takes place to such an extent as to cause a rapid in-
crease in the size of the liver, and almost to produce the alarming
symptoms of copious internal hemorrhage. Now and then, in-
deed, rupture takes place, and the blood escapes in large quantity
into the sac of the peritoneum. When the quantity of blood
effused in the substance of the tumors is small, the serum and
the colouring matter may be absorbed, and small masses of fibrine
be left.
But the most remarkable property of cancer — a property which
often influences the condition of the patient more than any da-
mage the disease does to the part in which it first appears — is its
power of dissemination. This varies much in degree, according
to the variety of cancer and the part of the body in which it
originates.
The laws which regulate the dissemination of cancer have not
been fully made out, but there is clear proof that the dissemina-
tion may take place in two ways : 1st, by inoculation, or by the
mere contact of a sound part with a part affected with cancer,
without any vascular connexion between them ; 2nd, by cancerous
matter conveyed by lymphatics and veins to other parts of the
body
lu the belly, where the relative motion between the surfaces is
x 2
308
CANCER OF THE LIVER.
great, we have now ancl then distinct evidence of inoculation, in
finding cancer communicated from one surface to another hy mere
contact, without adhesion. In a woman who lately died in King’s
College Hospital of cancer of the liver, there were small cancerous
tubercles on the under surface of the diaphragm corresponding to
a projecting cancerous tumor of the liver, although there were no
unnatural adhesions between the liver and the diaphragm, and no
cancerous tubercles on other parts of the reflected peritoneum.
In another woman who died of cancer which involved all the
organs in the pelvis, and led to secondary cancerous tubercles of
the peritoneum covering the intestines, the under edge of the
liver which had touched the tainted parts had its surface studded
with cancerous tubercles, while the substance of the liver, and the
upper part of its surface which was shielded hy the ribs, were free
from them. It was impossible to doubt that the edge of the liver
had been infected hy contact with the cancerous mass below.
Cruveilhier mentions a case in which he found cancer of the left
extremity of the pancreas with cancer of the upper part of the left
kidney. (Liv. xii. pi. 2, p. 5.)
It is chiefly in this way, — namely, hy inoculation, — that gelatini-
form cancer of the stomach or intestines becomes extended to
other organs in the cavity of the belly. In this variety of cancer,
the cancer-cells are too large to he readily transmitted hy the
veins so as to infect distant parts. It would seem, indeed, that
cells of gelatiniform cancer, when detached from the outer surface
of the stomach, may, like the fihrine which is effused in inflamma-
tion, become adherent to any part of the serous membrane with
which they are accidentally brought in contact, and may be nou-
rished from the vessels of that part. Cruveilhier (Liv. xxxvii.
pi. 3, p. 2,) relates a case in which, with gelatiniform cancer of
the stomach, there were cancerous tubercles of the peritoneum.
He particularly noticed that these were chiefly seated on those
parts of the peritoneum, which are subject to the least motion.
But the widest dissemination of cancer is effected hy the
transfer of cancerous matter hy lymphatics and veins to distant
parts of the body. The dissemination effected in this way
usually takes place in the direction of the current of blood, or
lymph. This is well shown, hy contrasting the organs that be-
come infected from cancer of the breast, a part from which the
DISSEMINATION OF CANCER.
309
blood is returned immediately to the vena cava, with the organs
that become infected from cancer of the stomach, a part from
which blood is returned to the portal vein. To take merely the
cases recorded by the writers before referred to — Cruveilhier,
Andral, and Farre. In the “ Anatomie Pathologique ” of Cru-
veilhier, there are, as before remarked, five cases, (Liv. xxiii. pi. 5,
p. 1 ; id. p. 2 ; id. p. 3 ; id. p. 4 ; Liv. xxxi. pi. 2. p. 3,) in which
cancerous tumors of the liver were consequent on cancer of the
breast. In all these cases, with the exception of one, (Liv. xxiii. pi.
5, p. 1,) in which the state of other organs is not mentioned, the
lungs were infected, as well as the liver. The cancer-cells had to
pass through the lungs, before they could arrive at the liver.
But although cancer of the breast seldom causes cancer of the
liver, without also causing cancer of the lungs, it not unfrequently
gives rise to cancerous tumors in the lungs, without giving rise
to any in the liver. In the Anat. Path, of Cruveilhier, three
cases of this kind are recorded. (Liv. xxvii.pl. 3, p. 1; id. p.5; Liv.
xxxi. pi. 2, p. 2.) Cruveilhier asks bow it happens, that in some
cases of cancer of the breast, secondary cancerous tumors form
in the lungs, chiefly ; while in other cases, they form in the liver,
chiefly ? The circumstance may be accounted for from the
variable size of cancer-cells, which are in some cases so small, as
to pass readily through the lungs ; in others, not.
When cancer originates in the stomach, secondary cancerous
tumors form in the liver, before they form in the lungs ; un-
doubtedly, from the blood infected with the cancerous matter
having to pass through the liver first. Indeed, it very seldom
happens that the lungs become affected at all. As before re-
marked, all the cancerous matter brought in the portal blood, is
usually detained in the substance of the liver, as are the globules
of pus in purulent phlebitis, instead of passing through to con-
taminate other organs. In the works already referred to, there
are thirteen cases in which cancerous tumors in the liver seemed
to be secondary to cancer of the stomach. In nine of these cases,
the liver was the only organ, besides the stomach, in which can-
cerous tumors were found. In the remaining four cases, there
was cancerous disease of some part of the mesentery, or of the
glands about the aorta, as well as of the liver. It is a striking
fact, that in not one was any cancer remarked in the lungs.
310
CANCER OF THE LIVER.
Cruveilhier relates seven other cases of cancer of the stomach.
In four of these, the disease was confined to the stomach ; in the
remaining three, all of them of gelatiniform cancer, there were
likewise cancerous tubercles in the mesentery, but in no other
organ.
When cancer originating in the kidney becomes disseminated,
the lungs are infected more frequently than the liver. It might
have been imagined, that the same law would hold for the uterus,
which, like the kidney, returns its blood immediately to the vena
cava ; but it sometimes happens, as in a case before related, (p. 305,)
that in consequence of cancer of the uterus, cancerous tumors
form in the liver, without any forming in the lungs. This results
from the primary cancer extending to the rectum, and involving
the hemorrhoidal veins, which return their blood to the vena
portae.
All these instances are sufficient to establish the fact, that
cancer often becomes disseminated by means of cancerous matter
which is conveyed onwards in the venous current. We have ad-
ditional proof of it, in the points of resemblance, before noticed,
between secondary cancerous tumors of the lungs and liver, and
the scattered abscesses which form in these organs in consequence
of purulent phlebitis.
It would seem, indeed, that cancer may even be propagated by
inoculation, or by injection of cancerous matter into veins, from
one animal to another.
Professor Langenbeck injected into the veins of a dog, some
pulp taken from a cancer which had just been removed from a
living body. At the end of some weeks, the dog began to waste
rapidly. It was then killed, and several cancerous tumors were
found in its lungs.
Another instance to the same effect, taken from a Germ all peri-
odical, is related in the Provincial Medical Journal for September
23, 1843, in the following words: “Some cells were collected
from a black liquid in tbe orbit of a mare affected with melanosis,
and were inoculated into the conjunctiva and lachrymal gland of
an old horse. These merely caused a black spot on the conjunc-
tiva, which extended very slowly ; but about the sixteenth week
after inoculation, melanosis of the lachrymal gland was very dc-
DISSEMINATION OF CANCER.
311
cided ; it had invaded the whole organ, and pushed the globe of
the eye forward. Some of the melanotic matter, taken from the
same mare, was injected into the veins of the neck of a dog, who
died suddenly, whilst hunting, three weeks after the operation.
There was found in the left lung a melanotic tumor, which was
ruptured, and which contained a brown, coffee-coloured fluid,
abounding in cells.”
So many instances have occurred of cancer of the penis, in men
whose wives had cancer of the womb, that many physicians have
been led to believe, that the disease, in these instances, was propa-
gated by contagion.
But the most obvious, if not the most common mode in which
cancer becomes disseminated from the part in which it first ap-
pears, is by transmission of the cancerous matter through the
lymphatics. It is through these vessels that cancer is so con-
stantly propagated from the breast to the glands in the axilla.
The small cancerous tubercles that are sometimes found sur-
rounding a cancer of the breast of long standing, are also, as was
beautifully shown by Sir Astley Cooper, seated in the lymphatics.
Cancer of the stomach may, as we have seen, give rise to dis-
seminated cancer of the liver, or to cancerous tubercles in the me-
sentery. In some instances of the latter kind, the presence of
the tubercles in the mesentery, may be best explained by sup-
posing cancer- cells to have been detached from the outer surface
of the stomach, and to have been transferred mechanically to other
parts of the serous membrane. But in other instances, the se-
condary tumors are clearly under the peritoneum, and in the
mesenteric glands, and the germs of the disease must have been
transmitted by lymphatics and lacteals.
In the lymphatics , cancer is propagated, not in the natural di-
rection of the current of lymph, only. It is sometimes propagated
backwards, as when, in cancer of the breast, cancerous tubercles
are found under the skin, not in the line to the axilla merely, but
surrounding the breast. This propagation of the disease back-
wards through the lymphatics, probably depends chiefly on the
onward course of the lymph being impeded. Cruveilhier has re-
marked that cancer of the breast leads less frequently to cancer
of internal organs, when the disease is thus disseminated outwardly.
It may be readily conceived, that obstruction in the course of
312
CANCER OF THE LIVER.
the lymphatics, leading to the axilla, or in the axillary glands, or
that adhesive inflammation of the veins, by blocking up the usual
channels for the transmission of the cancerous matter, may favour
the dissemination of this matter in the opposite direction, and
thus lead to the formation of cancerous tubercles in the neigh-
bourhood of the primary disease.
Admitting all these means for the propagation of cancer, there
are still cases, occasionally met with, which they do not enable
us to explain satisfactorily, and which strongly favour the infe-
rence, that the cancerous tumors found in different parts of the
body, are not offsets from one primary cancer, but are the result
of a peculiar disposition to the disease. There are, perhaps, few
cases in which such a supposition is more needed, than in cases
of primary cancer of the liver. In these cases, as when cancerous
tumors form in the liver in consequence of cancer of the stomach,
the infection does not often pass much beyond the liver, but
there are almost always a great number of cancerous tumors in
the liver itself. We have, at present, no evidence that these are,
in all cases, derived from a single parent tumor, but it seems
probable, that more careful observation will hereafter prove them
to be so. It is clear, at least, that dissemination may take place
within the liver, in various ways : — through the lymphatics, and
through the veins ; and, as before explained, in a twofold di-
rection in both.
Cancerous tumors may form in the liver, as a consequence of
cancer of some other part, at any period of life. They are in that
case dependent on the primary cancer, and of course are most
frequently found in conjunction with cancer of particular parts
at the periods of life when those parts are most liable to the va-
rieties of cancer which become readily disseminated. For the
Ireast, this is, perhaps, the period comprised between the ages of
thirty and fifty. Under the age of thirty, cancer of the breast,
of any kind, is very rare ; and beyond the age of fifty, the disease
is frequently schirrous, of slow growth, containing but few vessels,
and, in virtue of these conditions, less apt to become disseminated
than other varieties of cancer.
Cancer of the stomach does not occur so early in life as cancer
of the breast. It is very rare in persons under the age of forty.
DISSEMINATION OF CANCER.
313
Twenty cases of cancer of the stomach, recorded in the works of
Cruveilhier, Andral, and Farre, have been already referred to.
In eighteen of these, the age of the patient is noted, and in
all of them, it was above forty, with the exception of one, in
which it was thirty- eight. In eight of the cases, or nearly one
half, the patient was sixty, or upwards.
Dissemination from cancer of the stomach, is not much influ-
enced by age, but it seems to be much favoured by the occurrence
of ulceration. In the great majority of the cases just referred to,
in which cancerous tumors were found in the liver, the cancer of
the stomach was ulcerated. This may, however, be partly ex-
plained from the circumstance, that the soft varieties of cancer
which are the most favourable for dissemination, are also the most
prone to ulcerate.
Cancer of the uterus follows nearly the same laws, with re-
spect to age, as cancer of the breast ; and cancer of the colon and
rectum, as cancer of the stomach. But cancer of the uterus, and
of the large intestine, becomes disseminated much less frequently
than cancer of the stomach or breast.
The parts that have now been specified are by far the most
frequent seats of primary cancer, and since this disease occurs in
them only in the middle and advanced periods of life, dissemi-
nated cancer of the liver is also most frequent at those periods.
But cancerous tumors may form in the liver at any age, as a
consequence of cancer of some other part. Dr. Farre has given
the case of an infant, three months old, in which there was fun-
goid cancer of the left kidney, with fungoid tumors in the liver
and lungs. Another case, in a boy, two years and a half old, in
which numerous cancerous tumors of the liver, and a single can-
cerous tumor of the lung, were consequent on fungoid cancer of
the testicle : and a third case, in a boy of the same age, in which
there was a melanotic tumor in the pelvis, with cancer of the
lumbar glands, and cancerous tumors in the liver and lungs.
Indeed, secondary cancerous tumors form much more frequently
in the liver, in children affected with cancer, than in grown-up
persons, because children are subject only to the soft and very
vascular varieties of cancer, which, in direct reason of these
qualities, are the varieties which become soonest, and most widely
disseminated.
But, although cancerous tumors may form in the liver.
314
CANCER OF THE LIVER.
in consequence of cancer of a distant part, at any period
of life, the disease seldom, if ever, originates in the liver, until
the age of 35. In the five cases, before alluded to, in
which cancerous tumors seemed to have formed primarily in
the liver, one of the patients was 37 years of age, two were
39, and two were 45. In two cases, of which the particulars will
he given further on, the ages of the patients were 52 and 70.
The period, from 35 to 55, in which functional disorder of the
liver is most common, seems to he that in which cancer most fre-
quently originates in this organ.
Nothing more than this is known of the conditions that dispose
to primary cancer of the liver. We have no evidence that it is
more frequent in hot climates than in our own ; or in persons who
drink spirits to excess, than in those who abstain from them. It
has been found, with, perhaps, more than the average frequency,
in conjunction with gout and gall-stones, — so that it is probable,
that high living and indolent habits, which favour the production
of these latter diseases, may also dispose the liver to become the
primary seat of cancer.
In speculating on the cause of cancer, the question at once
arises : Is the germ of the disease a true parasite, introduced
from without ; or is it generated within the body, and of the ma-
terials of the body, under the influence of certain agencies ?
The strongest argument in favour of the first supposition, is,
that cancer originates in various organs, and has, in all of them,
independent vitality and powers of growth. This is shown in the
continued increase of the primary tumor, without any process
allied to inflammation, whatever be the age of the patient ; and
still more strikingly by the fact, which seems fully established,
that the mere lodgment of one or more germs from the original
tumor in a distant part, is sufficient, of itself, and independently
of constitutional predisposition, to communicate the disease to
that part. In cases in which the disease is propagated from one
animal to another, by inoculation, or by injection of the cancerous
matter into veins, it may, indeed, be considered parasitic, in the
strictest sense of that word.
But although cancer is capable of being thus directly implanted
from one individual to another, it occurs in almost all cases in cir-
cumstances in which it is difficult to believe that any such inoculation,
or infection, has taken place ; and not unfrcquently it appears to
CAUSES.
315
originate in some direct injury, or in prolonged irritation of the
part.
Thus cancer of the hreast is frequently ascribed to a blow, and
instances are now and then met with in which it is difficult to
avoid the conclusion, that it had really this origin. Cruveilhier
relates a case in which cancer of the breast, in a man, which is
a very rare disease, was consequent on a sabre- cut received
there.
Cancer of the lip is much more common in persons addicted to
smoking, than in others ; and probably originates in the irritation
of the pipe, or tobacco-juice. It is hardly ever met with in women,
and almost invariably occurs in the lower lip.
Cancer of the penis is found in undue proportion in men with
congenital pliymosis — in effect, probably, of irritation by long re-
tained and acrid secretions.
Cancer of the anus or rectum is said to he especially frequent
in persons who have had syphilitic vegetations, or piles. (Cruv.
Liv. xxv. pi. 3, p. 2.)
These instances go to bear out the old doctrine, that a disease,
which is not primarily malignant, may become so — a doctrine
which is in some degree at variance with the notion, that the germs
of cancer are always introduced from without.
Another instance to the same purport, more convincing than
any of those yet adduced, is the cancer of chimney-sweeps, which
appears to originate in prolonged irritation by soot. *
Perhaps the facts, that cancer does not occur in the mamma, or
in the uterus, before puberty ; and that it originates in the liver,
chiefly in the middle period of life, — give further support to the
doctrine, that the disease results from depraved nutrition of one
of the normal constituents of the part.
The structure of cancer affords additional reasons for rejecting
the notion, that the germs of the disease are always introduced
from without. The essential elements of a cancer, as of other
tissues, are nucleated cells and fibres. These cells multiply by
* An interesting case in which cancer of the hand was produced by the
handling of soot, in a gardener, who had long been in the habit of spreading
it over his beds as manure, is related by Mr. Travers, and is cited by my
brother. Dr. William Budd, in a paper published in the Lancet, in 1843, in
which the origin and propagation of cancer are fully considered, and from
which some of the instances adduced in the text have been borrowed.
fi
316
CANCER OF THE LIVER.
throwing off the germs of fresh cells from their outer surface ;
and sometimes also, as in colloid cancer, from their inner sur-
face.
All these circumstances give powerful sanction to the opinion,
that cancer originates in depraved nutrition of the original nu-
cleated cells of the part in which it first appears. We are ignorant
of the conditions which lead to this depraved nutrition, except in
the comparatively few cases in which the disease can he traced to
some direct injury, or to some palpable cause of irritation.
Cancer seems to depend less on the general state of nutrition,
and more on accidental conditions affecting the particular part,
than some other diseases — for instance, consumption, and scrofula
— which likewise result from faulty nutrition. It is not hereditary
in the same degree, and it very seldom originates, as the last
named diseases do, at the same time, or nearly at the same time,
in fellow organs, on the two sides of the body. It occurs also in
persons who are plethoric and seemingly robust.
Symptoms. Cancer of the liver comes on without marked con-
stitutional disturbance, and its early symptoms are very obscure.
When the disease originates in the liver, the patient usually com-
plains first, of uneasiness, and of a sense of fulness and weight, in
the right hypocliondrium, with impaired appetite, flatulence, and
other disorders of digestion.
After these ailments have lasted for some time, the medical at-
tendant, or perhaps the patient himself, discovers that the liver is
enlarged. The liver is felt extending across the epigastrium, or
below the false ribs, sometimes reaching as low as the umbilicus,
or lower, and not unfrequently an unevenness of its surface,
caused by the cancerous tumors projecting above it, can be dis-
tinguished through the walls of the belly. The patient now, or
even before this, suffers severe pain in the region of the liver, and
the functions of the organ are often hindered. In one case, there
is jaundice; in another, slight ascites; and sometimes, both these
symptoms occur at once.
In addition to these local symptoms, we may often remark some
of the sympathetic disorders — vomiting, a short dry cough, ri-
gidity of the abdominal muscles, pain in the right shoulder —
which have already been noticed as frequently occurring in abscess
of the liver.
SYMPTOMS.
317
The various disorders of digestion, usually with frequent vo-
miting, or retching, and with depression of spirits, continue ; and
the patient falls away in flesh and strength. When the tumors
grow rapidly, some degree of fever is usually set up : the pulse is
habitually rather frequent, the skin of the hands is often hot, the
appetite is capricious — in some cases, quite gone ; in others, on
the contrary, at times, almost ravenous — the bowels are sluggish,
the tongue is red and furred, and the urine is high-coloured,
and throws down a lateritious sediment, which is almost always
pinkish.
In advanced stages of the disease, there is often, as in cancer of
other parts, profuse sweating ; and the patient has aphthae of the
mouth, colliquative diarrhoea, and other tokens of defective nutri-
tion— and at length dies of exhaustion.
Such is the usual course of primary cancer of the liver, hut the
remark, which was made in a former chapter on abscess of the
liver, applies equally here — namely, that the local symptoms, on
which we rely most in forming our diagnosis, are far from being
uniform, or constantly present. The degree of enlargement of the
livei', and of pain or tenderness, and the presence or absence of
jaundice and of ascites — depend, mainly, on the number, and size,
and situation, of the tumors, on their rate of growth, and on the
inflammation which they happen to excite in their neighbourhood
— circumstances which vary iu every separate case.
Enlargement of the liver, which is the most constant, and by
far the most significant, of these local symptoms, in most cases,
varies in degree with the number and size of the cancerous tu-
mors. If the tumors be few in number, and small, there may
be no enlargement of the organ that can be discovered while the
patient is alive. But this very seldom happens. Almost always,
the liver is perceptibly enlarged, and in some cases it attains a
prodigious size. A case is related by Dr. Farre, in which the
liver, which was thickly studded with cancerous tumors, was
more than fifteen pounds, in weight. The enlargement of the
liver is constantly progressive, and in the soft and vascular varie-
ties of cancer, is so rapid, that, week after week, a further increase
in the size of the organ may be noticed.
318
CANCER OF THE LIVER.
The degree of pain and of tenderness depends, perhaps, chiefly
on the situation of the cancerous masses, and on their rate of
growth. When the tumors are deep-seated and of slow growth,
as when there are deep-seated abscesses, there may be no distinct
pain, or tenderness. When, on the contrary, the tumors are
superficial and grow rapidly, projecting above the surface of the
liver and stretching its capsule, and more especially when they
cause adhesive inflammation of the serous membrane above them,
the pain and tenderness are usually great.
The pain has not, as many writers have asserted, a particular
and constant character. In some cases, it is lancinating; in
others, not.
When the liver extends far below the false ribs, it may occa-
sionally be remarked, that the tenderness is greater at some
points than at others. It is greatest at those points, where
tumors project, or where circumscribed inflammation has been
excited in the serous membrane above them.
The presence or absence of jaundice, seems to depend, not so
mucli on the number and size of the tumors, and on their rate of
growth, as on their being so situated as to compress the common
or the hepatic duct, or one of its large branches. The liver may
be tripledin volume, without jaundice; and, on the other hand,
there may be deep jaundice, without appreciable enlargement of
the organ, and without pain or tenderness.
Jaundice is a frequent symptom in cancer of the liver ; occurring
probably, sooner or later, in the majority of cases. When it has
once come on, it continues till the death of the patient. It
results, in most cases, as stated above, from some of the gall-ducts
being compressed by the cancerous tumors ; but it may also
result from the ducts being closed by the growTth of cancerous
matter within them, and, perhaps, without any compression, or
closure, of the ducts, merely from much of the substance of the
liver being involved in the cancerous growths, and destroyed.
Ascites occurs much less frequently than jaundice. Its pre-
sence or absence, like that of the latter symptom, seems to depend
more on the situation of the tumors, than on their number and
size. Circumstances have already been mentioned, which render
it probable that the ascites results from obstruction to the flow of
SYMPTOMS.
319
blood through branches of the portal or of the hepatic vein, cither
from the pressure of neighbouring cancerous tumors, or from the
presence of cancerous matter, or of fibrine, in the vein itself. The
immediate cause of the ascites is clearly different from that of the
jaundice. Ascites may exist, without jaundice ; aud jaundice,
without ascites.
The quantity of fluid effused is generally small. As before
remarked, it happens but seldom that the belly is distended by
fluid, as it is in the advanced stages of cirrhosis.
The ascites may come on without pain. In some cases, indeed,
its occurrence relieves the pain, which the patient previously suf-
fered, by preventing the tender surface of the liver from rubbing so
much against the walls of the belly.
When ascites has occurred, it is, like jaundice, generally, if not
always, permanent ; a circumstance which tends further to show
that it results from some mechanical impediment to the passage of
the blood.
The degree of constitutional disturbance excited by cancer of
the liver, when other organs are sound, depends chiefly on the
rapidity with which the cancerous tumors grow and multiply.
When the tumors are scirrhous, they may, from their situation,
produce local, or special, symptoms — pain, or jaundice, or ascites,
— but they cause little fever, or other disturbance of the system at
large. When, on the contrary, they are very vascular, and grow
rapidly, there is usually an irritative fever, and the patient wastes
rapidly, even when no inflammation is set up about them.
The following case, for which I am indebted to my brother, Dr.
Richard Budd, of Barnstaple, is remarkable for the severe pain
and the rapid wasting caused by cancer of the liver, without any
inflammatory process.
Case. — Symptoms of indigestion — Lowness of spirits — Pain in the right hypo-
chondrium and right shoulder, which becomes agonizing — Enlargement of the
liver, sallowness, loss of appetite, retching, constipation, jaundice, oedema of
the feet, rapid wasting — Death after an illness of six months — Liver studded
with cancerous tumors — Cancerous disease of the gall-bladder and ducts —
A few of the neighbouring mesenteric glands tainted with cancer.
April, 1844.
M. T was a married woman, the mother of seven or eight children.
She was 52 years old, and had ceased to menstruate about four years. She
320
CANCER OF THE LIVER.
enjoyed remarkably robust health until last September, when her appetite
failed, and she became much depressed in mind. I was consulted in the first
week of December. She had then the ordinary symptoms of dyspepsia : —
loss of appetite, flatulence, foul mouth, costive bowels, and lowness of spirits.
Her complexion was sallow. She also complained of pain in the right hypo-
chondrium, and in the right shoulder. She was at this time quite strong,
and capable of attending to her domestic duties. The pain in the right side
rapidly increased, and soon extended over the epigastrium. On examination
about a week after I first saw her, the edge of the liver was distinctly felt
underneath the ribs, and was very tender on pressure. Before the end of
the month, she was confined to her bed, and the pain in the side, in the epi»
gastrium,and underneath the right shoulder-blade, had become agonizing. The
slightest examination caused exquisite torture, and from this time until her
death she was unable to lie down, and rested constantly on her hands and
knees. The liver increased in size gradually, and before she died formed a
large hard tumour below the ribs, extending across the epigastric region. As
the disease advanced, there was less and less desire for food, and there were
frequent and distressing retchings. The bowels were obstinately costive
throughout, owing, no doubt, in some measure, to the large quan-
tities of opium which were given to relieve her dreadful sufferings. The
evacuations from them were natural in appearance until about three weeks
before death, when they became white. The skin at the same time became
jaundiced, and the urine (which had always been scanty) loaded with bile.
Now also, I perceived some oedema of the feet. The rapid wasting of flesh,
from this time up to her death, which took place on the 11th of March, was
very remarkable. There was no fever from first to last, and until the last
moments the pulse was always good. The urine was loaded with lithates and
purpurates in a greater degree than I had ever witnessed before.
She attributed her disease to very great anxiety, which she experienced
last summer, but about eighteen months ago she received a severe blow on
the right side by falling with great force on the edge of her shop-counter.
She suffered severe pain in the side for some weeks after this accident, but
it gradually passed away, and she got, apparently, quite well.
She was a highly respectable woman, of a healthy stock, and of in-
dustrious and temperate habits.
On examination after death, the liver was found of large size, and its left
lobe reached over the stomach into the left hypochondrium. The whole
lower edge was converted into cancer, and indeed the whole organ was
studded with it so as to present when divided at least two-thirds of cancer
for one of liver. The ductus communis and the cystic duct were obliterated
by cancerous matter, and the gall- bladder, which contained about a teaspoon-
ful of inspissated bile, was covered with cancer granules. A few of the me-
senteric glands in the vicinity of the stomach were tainted. The rest of the
contents of the abdomen were healthy, and there was not the slightest perito-
neal adhesion in any part. The kidneys were of natural size, and deeply
tinged with bile. The right kidney appeared to be quite healthy, but the left was
SYMPTOMS.
321
flabby, and paler than natural, and its cortical substance showed some signs
of fatty degeneration.
The left ovary was as large as a hen’s egg, of a very dark, almost chocolate,
colour, and there were two serous cysts attached to it by pedicles.
The heart and the lungs were quite sound, and there were no pleuritic
adhesions.
The cancerous tumors were generally white, except where they were
crossed by injected vessels ; but about the circumference of some of the large
tumors, and in some of the small ones throughout, the cancerous matter
was tinged of a deep green with bile.
In the following case which lately fell under my care in King's
College Hospital, the disease proved fatal just as rapidly, but the
symptoms were in many respects different. There was much less
pain, and ascites occurred instead of jaundice. The most re-
markable feature in the case is perhaps the absence of anything
like a pink deposit in the urine.
Case. — Pain and tenderness in the right hypochondrium — Retching — Loss of
appetite — (Edema of the legs — Enlargement of the belly — Liver large and
nodulous — Loss of flesh — Death from exhaustion after an illness of seven
months — Liver studded with projecting medullary tumors — Some small can-
cerous tumors in the mesentery, near the liver — A single cancerous tumor in
the left lung.
Ann Cleal, set. 70, a widow, was admitted into King’s College Hospital, on
the 27th March, 1844.
She was born in London, and always lived there ; has had six children ;
the latter part of her life has gained her living as monthly nurse.
She was confined for her first child at the age of 22, and from that time to
the present, has had occasionally, — as often, on an average, as once in six
weeks, — a sudden attack of pain in the lower part of the belly, attended with
vomiting and purging. These symptoms usually continued a day or two, after
which she soon recovered. Was never jaundiced in any of these illnesses.
Since the age of 50, has been likewise subject to rheumatic pains in the
limbs, but has never had rheumatic fever.
With the exception of these ailments, her health was good until twelve
months ago, when she had severe diarrhoea, which lasted five weeks.
Six months ago, began to have pain and tenderness in the right hypochon-
drium, together with retching, which occurred five or six times a day, with-
out nausea, or other warning, and which ended in her bringing up from the
stomach a clear phlegm.
In the month of December, between two and three months after the occur-
Y
322
CANCER OF THE LIVER.
rence of these symptoms, she lost her appetite, and became thirsty, and had a
sensation of numbness in the legs and thighs. This had continued a fortnight,
when she perceived that her ankles were oedematous. In two or three days
more, the legs and thighs were in the same state. Soon after this she fancied
that her liver, to use her own expression, “ was in lumps.”
The swelling of the legs continued, and about a month ago she remarked,
for the first time, that her belly was swollen. Since then, the belly has been
rapidly enlarging.
The pain under the right false ribs has continued, but does not seem to
have been ever very severe. The retching also has continued to recur, but
less frequently than at first. It has always ended in the discharge of a clear
phlegm, which has been generally insipid. Has never vomited her food.
Latterly, her appetite has failed, and food, taken even in small quantity, has
caused pain, and a sense of fulness, at the stomach.
At the time of her admission into the hospital, she was sallow, and much
emaciated. There was great oedema of both legs, hut none of the arms or
face. The belly was very large and fluctuating, but its walls were not tense,
and through the fluid in the peritoneum a number of round tumors, of the
size of small oranges, could be distinctly felt, occupying all its upper part as
low as the umbilicus. These tumors felt hard. She complained of slight
soreness when they were pressed, and of an aching for some time after, but
otherwise was free from pain, except on turning in bed, when she had pain
under the right false ribs, and in the back. She had no appetite, and was
occasionally thirsty. Had retching once or twice a day. The bowels were
regular. The tongue was red, covered with a yellowish-white fur, and rather
dry. The pulse, which was regular, was 84, and the inspirations were
22, a minute. There was no cough or difficulty of breathing, and no unna-
tural heat of skin. The urine was scanty, slightly acid, and turbid with pale
lithates.
She remained in the hospital until the 22nd of April, when she died rather
suddenly, and apparently from exhaustion.
There was little change in her condition from the time of her entering the
hospital, except that she grew weaker, and that latterly the oedema somewhat
increased, so that for nearly a fortnight before her death her hands were
slightly puffed.
On the 15th of April, it was noticed that slight pressure on one of the
tumors at the epigastrium caused a very distinct creaking, like that of new
leather. This creaking could be felt, more or less marked, from that time to
her death. Nothing of the kind was perceived when the other tumors were
pressed. The pain under the right false ribs, and in the back, continued,
hut was never severe. It was most felt on her turning in bed. The tumors
were always slightly tender, but never so much so as to cause her to complain
when they were examined guardedly. She had never feverish heat of skin.
The pulse was always regular, and until the 14th of April, it ranged from
70 to 80, a minute : from the 14th to the 19th, it was always between 80 and
90; from the 1 9th to her death, from 90 to 96. The breathing was never
distressed. The number of inspirations was often counted, and was never
SYMPTOMS.
323
found higher than 24 a minute. The tongue continued red, rather dry, and
covered with a rough, yellowish-white fur. She had very little appetite, and
at times complained of thirst. Retching was less frequent than before her
admission to the hospital, so that she sometimes passed two or three days
without it. The bowels were somewhat confined, but they were readily
moved by small doses of castor oil. The urine was frequently examined. It
was always acid, and generally turbid with pale lithates. Two or three
times, it was found quite clear, and on one of those occasions, (on the 12th
of April,) it had deposited lithic acid gravel. It never threw down a sedi-
ment approaching to pink. It was always passed in very small quantity, but
its specific gravity, when measured, did not exceed 1*021. It never con-
tained albumen.
She had no disorder of intellect, and no impairment of the senses, until the
day before her death, when it was remarked that she had grown deaf. On
some nights, she slept but little ; on other nights, well.
On her admission to the hospital, she was ordered five grains of trisnitrate
of bismuth, three times a-day ; which, she fancied, rendered the retching less
frequent, and which she continued to take until the 11th of April, when it
was exchanged for a saline draught, containing ten grains of nitre, three
times a-day. Occasionally, three drachms of castor oil were given to act on
the bowels.
She was kept on milk diet.
The body was examined thirty-seven hours after death.
It was much emaciated, and the skin was slightly sallow. The legs were
very oedematous, and the arms slightly so. The belly was enormously dis-
tended with a yellowish, serous, fluid of specific gravity 1-015.
When the belly was laid open, the liver presented a strange appear-
ance. It was much enlarged, and that part of its surface which extended
below the ribs was extremely deformed by large medullary tumors. When
it was cut into, every portion of it, except the part near the diaphragm, and
a portion of the right lobe that was shielded by the ribs, was found to be
studded with such tumors, from the size of a walnut to that of a large
orange. The larger of the tumors projected much above the surface, and were
felt during life. In two or three of these, the projecting portion had its
surface hollowed, or cup-shaped; in the others, it was spherical. There
were no marks of inflammation of the capsule of the liver. On pressing
the tumor over which the creaking was felt during life, which was one of
those whose projecting portion was cupped, the same creaking was still per-
ceived. It originated within the tumor. None of the other tumors gave
a feeling of this kind. The liver, with the tumors, weighed seven pounds.
The tumors were vascular, and the larger of them, when sliced through
the middle, presented somewhat of a radiated arrangement of fibres con-
verging to the centre. Their texture was not everywhere the same. The
larger tumors near that part of their circumference which was sunk
in the liver, and the smaller tumors throughout, were pulpy, and on slight
pressure, gave issue to an opaque white fluid, which, under the microscope,
Y 2
324
CANCER OF THE LIVER.
exhibited round or oval cancer-cells, the largest of which were about j^th
of an inch in diameter. These portions of the tumors presented a mottled
appearance, as if the cancerous matter had been deposited in the lobules,
without completely effacing them. The central and the projecting portions
of some of the large tumors were much firmer, and had a glassy, or gela-
tinous appearance, with here and there a spot of ecchymosis. When these
portions were squeezed, a transparent, colourless liquid, like water, escaped.
There were no marks of inflammation in the substance of the liver round
the tumors. At some points, where two adjacent tumors nearly touched,
the hepatic substance between them was compressed, and some hepatic
veins in such portions were flattened. At other points, all the intervening
hepatic substance seemed to have become involved in the growth of the
tumors which touched each other, or were merely separated by a fissure
in which ran a gall-duct, tinged with bile. It was clear that the cancerous
matter was deposited inter stitially in the hepatic substance, and that it did
not merely push this substance aside. This was also shown by another
circumstance; namely, that in the midst of some of the larger tumors,
when these were cut across, a vessel of considerable size was found, which
had the characters of a portal vein. The hepatic tissue in those portions of
the liver which were free from tumors seemed to be healthy. The hepatic
cells contained a good deal of yellow granular matter, but not many oil-
globules.
The portal and the hepatic veins were healthy. The gall-ducts were
pervious, and, as well as the gall-bladder, appeared to be healthy.
A cancerous tumor, of the size of a walnut, and two or three smaller ones,
were found between the transverse fissure of the liver and the lesser curvature
of the stomach.
A single medullary tumor, nearly as large as a walnut, was found im-
bedded in the lower lobe of the left lung. No tumors of this kind were
discovered in other parts of the body.
The place of the right ovary was occupied by a thin, tough, fibrous-look-
ing cyst, like the outer fold of the pericardium, of the size of the fist, and
filled with a blackish-red, clear fluid, of sp. gr. 1037. This cyst, which
probably originated in a Graafian vesicle, was united by narrow bands of
false membrane, two or three inches in length, to the brim of the pelvis,
and to some loops of intestine. The fluid within it contained so large
a quantity of albumen, that the precipitate which formed on the applica-
tion of heat, or on the addition of nitric acid, was almost abundant enough
to render the whole solid. It contained also a considerable quantity of common
salt ; but no lime, potash, fat, or iron, were detected in it by the usual tests.
The uterus, and the rest of the generative organs, were healthy.
The stomach was quite sound, and its mucous membrane was of natural
firmness.
The intestines were not laid open. On the outside they appeared to be
everywhere sound.
The spleen was soft, and weighed five ounces and a half.
DIAGNOSIS.
325
The lungs were free from adhesions, and, but for the solitary cancerous
tumor in the left lung, were quite sound.
The heart was somewhat enlarged from dilatation of its chambers ; and
the edges of both the mitral and the aortic valves, were slightly thick-
ened.
The aorta, within the chest, presented much * atheromatous’ deposit on
its inner surface, and many calcareous plates. In the belly, it was still more
diseased, the calcareous plates running together and almost converting
some portions of it into a bony cylinder. The renal arteries were smaller
than natural.
The kidneys were small, each weighing about four ounces and a half.
Their surface was sprinkled with projecting cysts, from the size of a small
shot to that of a small pea, and filled with a clear, colourless liquid. When
these organs were sliced, their cortical substance seemed to be wasted, and
presented a great number of minute white specks, which were just visible
to the naked eye. In the tubular portions, white matter of the same kind
was seen in fines which had the direction of the tubules.
The cerebral substance forming the septum lucidum and the fornix,
was much softened; and the matter of the entire brain was softer than
natural.
No other marks of disease were discovered.
In this case, the cancer originated, without doubt, in the liver,
and was propagated by the lymphatics to the neighbouring me-
senteric glands, and thence, probably, to the lung.
The disease of the right ovary occurred probably during the
first pregnancy of the patient, or soon after, and was the cause
of the sudden attacks of pain in the lower part of the belly, to
which she was so long subject.
The small size of the kidneys resulted, perhaps, from their
having for a long time received an insufficient supply of blood,
in consequence of the diseased state of the abdominal aorta. The
white matter deposited in them, which was different in appearance
from that found in ordinary granular degeneration, might also
have resulted from this condition.
We are ignorant of the conditions which dispose to primary
cancer of the liver, or which immediately excite it, so that in the
diagnosis of this disease, we are little helped by knowing the
previous habits of the patient, or the circumstances in which he
has lately been placed. We know only that the disease does not
occur before the age of thirty-five. In persons above this age,
326
CANCER OF THE LIVER.
it can only be discovered by the intrinsic import of the symptoms.
But in the early stages of the disease, and while the liver is still
shielded by the ribs, the symptoms are vague, and such only as
are common to various derangements of this organ. They may
justly excite our fears ; but they cannot give us assurance that
the liver is the seat of cancer.
The most significant symptom is enlargement of the liver.
When this comes on in the middle period of life, and especially
when it is progressive, and when other conditions that may
equally give rise to it, are wanting, — when there is no obstacle
to the circulation in the chest, when the patient is not consump-
tive, and when his habits have not been such as to lead us to
suspect that he may have cirrhosis, — it affords, of itself, strong
presumption of the presence of cancerous tumors. When the
liver is of very great size, and its surface can he felt to be
nodulous or uneven, there is no longer room for doubt.
Another symptom which is of very frequent occurrence, and
which may help us to distinguish this disease from some others in
which the liver is likewise enlarged, is constant pain and tender-
ness.
A small, permanent collection of fluid in the cavity of the
peritoneum, when there is no reason to believe it to be the result
of cirrhosis, is another significant token of the presence of can-
cerous tumors in the liver. A large quantity of fluid in the
peritoneum is less significant of itself, and it may even increase
the difficulty of diagnosis, by preventing our feeling the large and
nodulous liver.
When cancer of the liver is consequent on cancer of some other
part, its detection is much easier, because, from our knowledge
of the frequent dissemination of cancer, symptoms, which are in
other circumstances trivial, then acquire great significance. In a
woman who has ulcerated cancer of the breast, with the general
symptoms of the cancerous cachexy ; or in one who has cancer
of the uterus which has eaten into the intestine ; or in a person
who has presented for some time the symptoms of cancer of the
stomach,— pain and tenderness in the region of the liver, or a
slight increase in its volume, with jaundice, or slight ascites,
or even one of these symptoms, are evidence enough that can-
cerous tumors have formed in this organ. The same symptoms,
7
TREATMENT.
327
occurring soon after an injury to the head, or after amputation of
the leg or arm, together with the constitutional symptoms of sup-
purative phlebitis, would scarcely leave a doubt that abscesses
were forming in the liver. Our conclusions are drawn, not so
much from the intrinsic value of the symptoms, as from the sig-
nificance which these derive from the circumstances under which
they occur.
The treatment of malignant disease of the liver should be
simply palliative. Practitioners have, indeed, hoped to destroy
cancerous tumors by some powerful alterative, or, if not to de-
stroy them, at least to retard their growth. Various powerful
medicines — alkalies, mercury, arsenic, iodine — have been tried
in turn with this view, and all, — it is almost needless to remark, —
have signally failed. They have aggravated suffering and has-
tened death, by adding their own noxious effects to those of the
malady ; hut there is no evidence that they have ever in the
slightest degree retarded the growth or prevented the multiplica-
tion of the tumors. We can, indeed, hardly expect ever to effect
this by medicines of any kind — seeing that cancer is not destroyed
by any injury short of entire removal, and that it never loses its
vitality by any change in the patient’s constitution. The objects
of rational treatment are, then, to mitigate the pain and any in-
flammation that may he caused by the cancerous tumors ; and to
retard the emaciation and exhaustion which they produce.
For the relief of the pain, which is often quite independent of
inflammation, we have no means hut narcotics, which are very
useful for this end, more especially in advanced stages of the dis-
ease. The most efficient of these remedies are the different pre-
parations of morphia and conium.
Any inflammation of the peritoneum that may be excited by
cancer of the liver, will be best relieved by the application of a
few leeches, or by taking away a small quantity of blood from
the side by cupping. The diminution of tenderness from these
means is often great, and before the strength of the patient is
much reduced, there are no countervailing evils which should
deter us from their use. When the patient has become some-
what low in condition, we should, of course, be chary in talcing away
blood ; and but little benefit can be expected from other active mea-
sures. Any good to ho obtained from blisters, or other modes of
328
KNOTTY TUMORS OF THE LIVER.
counter-irritation, will seldom compensate for the torture and the
weakness which they occasion. In the advanced stages of the
disease, blisters are never advisable, since in the cachectic con-
dition produced by cancer, and, indeed, in persons much reduced
by any organic disease, they often cause severe pain, and give
rise to irritable ulcers of the skin. The strength of the patient
should be supported by a light, nourishing diet; and we should
carefully abstain from mercury, iodine, strong purgatives, and
all other powerful and lowering medicines. The wisdom of the
practitioner is best shown in his abstaining from all fruitless in-
terference.
In no cases, perhaps, has the specific influence which has been
long attributed to mercury in the treatment of liver diseases,
done so much harm as in cases in which this organ has been the
seat of cancer. In its early stages, the disease is often set down
vaguely as enlargement, or obstruction, of the liver, and mercury
is given in consequence. In this country, indeed, a few years
ago, the patient was fortunate if he escaped salivation, even after
the tubera could be plainly felt, or when the existence of
cancer elsewhere should have left no doubt as to the nature of
the disease of the liver. In eight out of ten cases which have
been recorded by Dr. Farre, the patient was mercurialized. In
some of these cases mercury was given, or its use was continued,
after the tumors in the liver were felt. In three of the cases in
which it was given, the patients were young children.
In cases such as these, it is happy for the patient, if the phy-
sician sees the true scope of his power, and is especially careful
to do no harm where, confessedly, he can do but little good. Dr.
Farre makes some judicious remarks on the error that was com-
mitted in the cases which he has recorded, in making ineffectual
efforts to cure, where the treatment should have been simply
palliative. As he well observes, “ the perfection of medicine
consists, not in vain attempts to do more than nature permits,
but in promptly and effectually applying its healing powers to
those diseases which are curable, and in soothing those which arc
incurable.”
Encysted knotty tumors of the liver.
In connexion with cancerous tumors of the liver, it will not be
altogether out of place to describe tumors which are now and then
KNOTTY TUMORS OF THE LIVER.
329
met with in this organ, and which, although essentially different
from cancerous tumors, resemble them somewhat in appearance,
and have been generally confounded with them. The tumors I
allude to, are the encysted tumors, containing a cheese-like
matter, which have been cursorily noticed in a former chapter,
(p. 154). From their nodulous form in the specimens which have
fallen under my notice, I have ventured to call them “ knotty
tumors of the liver.”
The first instance of this disease that I met with occurred in a
man who had been a hard drinker, and who died under my care,
in the Dreadnought, in 1838, at the age of 32. The liver pre-
sented marks of extensive adhesive inflammation. It was en-
larged, its surface was uneven, its edges were rounded, and its
convex surface was united to the diaphragm by tufts of old false
membrane. It contained several solid tumors, — the largest of
them about the size of a walnut, — -which were composed of an
uniform, firm, yellowish-white substance. The disease struck me
at the time as being different from cancer, but no close examina-
tion of the tumors was made. There was no similar disease in
any other part of the body.
In the spring of 1844, I had an opportunity of closely examin-
ing some tumors of the same kind in a liver which was sent to
me by Mr. Busk, and which was taken from a man who died in
the Dreadnought, of fever. The liver was of moderate size, and
adhered to the diaphragm in patches. It contained about a dozen
firm, white, fibrous-looking tumors, from the size of a large pea
to that of a walnut. Most of these tumors were imbedded in the
fiver, hut two or three of them reached its surface, and the fiver
was adherent to the diaphragm at those spots. One of the
tumors projected above the surface, and the hepatic tissue around
the others seemed to be compressed. The larger of the tumors
were very nodulous, and all of them, large and small, were sur-
rounded by a thin, but well defined cyst. They appeared to ho
all situated in portal canals, and were composed of a compact
substance, of a dead white colour, to the eye not unlike firm
white cheese. This substance was tough, like the fibrine of in-
flammatory blood, and adhered firmly to the cysts.* Some of
* One of these tumors is preserved in the museum of King’s College.
(Prep. 327.)
330
KNOTTY TUMORS OF THE LIVER.
the tumors had at their centres a small cavity, (about the size of
a partridge-shot,) filled’ with a greenish matter, which had the
appearance of inspissated bile.
The clieese-like substance of which the tumors were composed,
exhibited under the microscope a mass of irregular granules, (which
was not much altered by acetic acid,) with some free oil-globules,
and with, here and there, a plate of cholesterine. No fluid could
he pressed out of it, and it presented no trace of organization —
no fibres or cells. A slice of it digested for twenty-four hours in
cold muriatic acid, gave a violet solution ; showing that it was
allied in composition to albumen or fibrine.
The greenish matter which was found at the centres of some of
the tumors, presented, under the microscope, a great number of
oil-globules, plates of cholesterine, and shapeless masses of an
orange-yellow, of various sizes, mixed with irregular, transparent,
colourless granules. On a drop of nitric acid being added to the
specimen under the microscope, the orange-yellow masses imme-
diately became of a rich marine blue, but remained perfectly
distinct. After the glass had been heated, these objects were in-
distinct, hut round purplish globular masses were here and there
seen.
The tumors seemed to be of long-standing. There was no
similar disease in any other part of the body, nor were there any
marks of scrofula, and the person did not appear to be of scrofu-
lous habit.
The hepatic substance was in an early stage of cirrhosis ; and
the hepatic cells were unusually small, and contained but little
oil.
The bile in the gall-bladder was reported by Mr. Clapp, who
examined the body, to he of natural appearance.
A short time before this examination was made, I received from
Dr. Inman, of Liverpool, some notes of a case in which tubera
were found in the liver, which, from Dr. Inman’s description, I
inferred to he of the same kind as those which have just been
described. At my request, Dr. Inman sent me one of the tumors,
and my inference proved to he correct. The case is further inter-
esting as illustrating the tendency, noticed in a former chapter,
which gangrene of an external part has to produce gangrene of
KNOTTY TUMORS OF THE LIVER.
331
internal organs, and I shall therefore relate it at length in Dr.
Inman’s words : —
Case. — Pain in the region of the liver, more or less severe, for eighteen months
— Gonorrhoea — Gangrene of the labia and perineum — Death — Four gan-
grenous cavities in the right lung, and one abscess — Many small abscesses in
the left lung — Large knotty tumors in the liver.
(Jan. 31, 1844.)
“ Maria Sprounds, set. 31, a market-woman, of loose habits, but not in-
temperate in drink, was admitted into the Lock with deep sloughing of the
vulva and perineum, which extended backwards over the whole sacrum.
The day before her death, when I first saw her, the parts were black, and
emitted a most disgusting smell. Her breathing was hurried, — the inspira-
tions being forty-four a minute, — and she had cough with expectoration of a
thin, serous fluid, not unlike apricot-juice. The odour of gangrene from the
vulva was so strong that it was very difficult to say whether the breath was
fetid or not. The pulse was 120, and small. She lay on her right side, and
did not complain of any pain.
“ The following particulars I learned from her sister. — She was always
healthy till eighteen months ago, when she began to suffer pain in the region
of the fiver, which has continued, more or less severe, ever since. Six
months ago, she had a venereal complaint, which soon got well. She was
not compelled to leave her habitual employment until three weeks before her
death. She then complained of pain and swelling of the pudenda, the
venereal origin of which she most stoutly denied to her death. At first,
there was simply swelling of the labia externa, which soon became black;
the skin then broke, and the whole of the vulva began to slough ; the gan-
grene spread rapidly over the sacrum, but not laterally, towards the nates.
In this condition she was taken to the Lock, where she died a week after.
The nymphae, the clitoris, and the vagina, were all included in the slough.
“The body was examined eighteen hours after death.
“ In the right pleural cavity there was a large quantity of opaque serous
fluid, and both the costal and the pulmonary pleurae, were coated by a
recently-formed false membrane. The lung was adherent to the side at a
spot corresponding to a cavern, which existed immediately beneath the pul-
monary pleura in the middle lobe. On the left side of the chest there was
likewise a turbid serous fluid in the pleural cavity, and both the costal and
the pulmonary pleurae were covered with false membrane, but the inflamma-
tion had not been so intense as on the right side.
“ The right lung was carnified in great extent, and on its middle lobe being
cut into, a gangrenous cavern was found, fined by a thin false membrane,
and containing a diffluent substance, of repulsive smell, which, when sub-
jected to a stream of water, left a rough, irregular, mesh of partly mortified
pulmonary substance. In the vicinity of this cavity, there were three others,
332
KNOTTY TUMORS OF THE LIVER.
which were smaller, hut like it in other respects. There was also a small
collection of pus in this lung.
“ The left lung contained a great many small cavities, lined hy a delicate
cyst, and containing a thick yellowish matter, like concrete pus or softened
fibrine, which was insoluble in water, hut was easily washed away. These
existed in all parts of the lung, hut seemed to be most numerous near its
surface and edges. This lung also was carnified in great extent. No tu-
bercles existed in either lung. There was some fluid in the pericardium, hut
the heart was healthy.
“ The liver, which was of natural size, contained three yellowish-white
bodies, which projected a little above its surface, and were attached to the
walls of the belly by bands of false membrane about three inches in length.
The smallest of these tumors was about the size of a Spanish nut, and was
situated at the acute margin of the left lobe. The largest of them was
situated at the junction of the right and left lobes, and appeared to be made
up of several smaller ones, each of them contained in a cyst. They do not
appear to have had any influence on the hepatic substance, as that part of
it which is in immediate contact with them does not seem to be denser than
natural.
“The stomach, the intestines, the kidneys, the uterus, the mesentery, and
the peritoneum lining the pelvis, were all healthy. The internal iliac veins
were healthy, and contained no pus.”
A portion of the liver containing one of the tumors, which
was sent me by Dr. Inman, is now in the museum of King’s Col-
lege, (Prep. 326). This tumor, which is as large as a moderate
sized potatoe, is widest at the surface of the liver, and projects
slightly above it. It is round, hut has an irregular surface, not
unlike that of a mulberry calculus. The knotty projections are
not distinct tumors, as Dr. Inman supposed, hut mere excres-
cences. They are all included in a common cyst, which although
very thin, is readily distinguished, from its being more transparent
than the substance it contains.
The tumor was evidently formed in a portal canal. A portal
vein of considerable size can he traced into its capsule, round
which it winds for some distance. The substance of the tumor
is precisely of the same character as that of the tumors in the
liver which was sent me hy Mr. Busk. It is of a dead white, or
rather faint yellowish-white, firm, smooth when cut, and appa-
rently homogeneous, not unlike firm white cheese. As happened
in the tumors before described, it adhered firmly to the inner
surface of the cyst. Under the microscope, it exhibits a granular
matter, and some small free oil globules, hut no plates of choles-
terine. The granular matter is rendered a little more transparent.
KNOTTY TUMORS OF THE LIVER.
333
but not much more so, by the addition of a drop of acetic acid.
The substance of tlie tumor contains less oil than tliat of the
tumors of the same kind -which I had before examined. A par-
ticle picked out from the centre of the tumor, showed small
orange-coloured masses, which seemed to be composed of the
colouring matters of bile. The substance of the tumor exhibits
no trace of organisation — no fibres or cells. A small slice of it,
weighing 4*6 grains, which was dried by my friend, Dr. Miller,
at 200° F., left an ash amounting to 0T5 grains.
In the museum of King’s College, (Prep. 328,) there is another
preparation, showing a portion of liver, which contains three
tumors, evidently of the same kind as those just described. No
history of the case is given.
The tumors are about the size of hazel-nuts, and reach the
surface of the liver, which at those spots is covered by a false
membrane. The matter composing them is more friable than in
the former cases, and exhibits under the microscope irregular
granules, with here and there an orange-yellow mass, that appears
to consist of biliary matter, and also a few plates of cliolesterine,
and some round globules of solid matter, which refract light
strongly, and some of which exhibit faint rays proceeding from
the centre. These globules were most of them dissolved when
a drop of ether was put on the glass under the microscope, and
were probably composed of stearine.
A fresh section was made of two of these tumors, and a small
mass of concrete biliary matter was found in the centre of each,
exactly as in the tumors which were sent to me by Mr. Busk.
In this specimen, there is a good deal of green biliary matter
in the hepatic substance, and at a spot near the tumors a small
biliary concretion.
From the examination of these tumors, it would seem that they
are analogous to the glairy cysts described in a former chapter,
and that they result from dilatation of portions of the hepatic
ducts by matter secreted by their mucous membrane. This ex-
plains their being encysted, and also another circumstance, which
I noticed when examining them, — namely, that the cyst is not
thicker in the large tumors than in the small. It explains, too,
the presence of biliary matter in the centres of all these tumors.
The circumstance that, in all the specimens, an old false mem-
334
KNOTTY TUMORS OF THE LIVER.
brane covered the tumors which reached the surface, hut not other
portions of the liver, showed that an inflammatory process attended
their formation.
It would appear, therefore, that the disease commences as in-
flammation of the mucous membrane of the hepatic ducts — that,
in consequence of this, a duct becomes closed at some point,
and the portion behind distended into an irregular pouch by
the matter subsequently secreted. This origin explains the
absence of any trace of organization in these tubera. The matter
which is poured out on the free surface of an inflamed mucous
membrane, is not susceptible of organization ; but, if it be pent
up in a closed cavity and do not contain much pus, forms at
length a cheese-like mass, as in these tubera.
Encysted cheesy masses of the same kind are occasionally
found in the lung ; and they may also form in the kidney.
The cheesy-matter of a scrofulous gland originates in the same
way — from inflammation of the mucous membrane of the gland.
Small tumors containing a cheese-like matter, are now and
then found under the skin, especially on the inside of the upper
arm ; and which probably originate in circumscribed inflammation
of the lymphatics.
Tubera of this kind can only form in mucous tubes which are
small, and which, — as the lymphatics, the hepatic gall-ducts, and
the small bronchial tubes, — have, in fulfilling their natural office,
but a feeble current through them.
Abercrombie, in his work on the stomach and intestines, has
given a short chapter on tumors of the land under consideration,
and has classed them with glairy cysts of the liver. The chapter
is headed, “ Tubera of the liver without other disease of its
structure.” He says, “ These tubera present externally a surface
elevated into irregular knobs, of a yellowish or ash colour, and
perhaps from two or three inches in diameter. Internally they
exhibit a variety of textures — in some cases fibrous, in others
tuberculous or cheesy, and frequently there are cysts containiug
a viscid fluid. It appears that they produce marked symptoms,
only when they are numerous or accompanied by enlargement of
the liver, or disease of its general structure ; but that when the
structure is otherwise healthy, they may exist without any symp-
toms calculated to give a suspicion of their presence. Of this I
shall only give the following example.” (Diseases of the Stomach,
2nd edit. p. 367.)
KNOTTY TUMORS OF THE LIVER.
335
Tlie example given by Abercrombie is the case of a gentleman,
aged 80, who had enjoyed uninterrupted good health until a few
weeks before bis death, when lie became one day suddenly inco-
herent. This disorder of intellect was removed by purgatives,
and he had not shown any other symptom of disease, when one
morning he was found dead in his bed. “ No morbid appearance
could be discovered to account for his sudden death, except that
all the cavities of the heart, the aorta, and the vena cava, were
completely empty of blood. On the convex surface of the liver,
there was a tumor about three inches in diameter, elevated into
numerous irregular knobs ; on cutting into it a cavity was exposed
capable of holding about jviij , and full of an opaque ash-coloured
fluid, which could be drawn out into strings. The liver in other
respects was perfectly healthy.”
For a more particular account of these tubera, Abercrombie
refers to the work on the morbid anatomy of the liver, by Dr.
Farre, in which, however, only cancerous tumors of the liver are
described.
33G
Sect. II. — Hydatid tumors of the liver.
Hydatid tumors, like cancerous tumors, are more common in
the liver than in any other organ.
They consist of a sac, of peculiar character, which is closely
lined by a thin membranous bladder, or cyst, and filled with
fluid, which is usually colourless and limpid as the purest water.
In some cases, on a superficial examination, nothing more than
this appears ; but generally, in hydatid tumors in man, there are
found floating in the liquid a variable number (sometimes many
hundreds) of globular bladders or cysts, similar to that which
lines the sac, but of various sizes, from that of a small pea to
that of a walnut. To these bladders, Laennec gave the name,
Aceplialocyst, — from aKe4>a\r] kvo-t — a bladder without a head.
The sac, which seems to be formed of condensed hepatic tissue
and the remains of obliterated vessels, has just the same character
whether it contain merely the cyst which lines it, or many
floating acephalocysts besides. Its thickness varies with the size
and age of the tumor, and perhaps also with the degree of
resistance which it has experienced in its growth. In small and
recently formed tumors it is very thin ; hut in large tumors of
long standing, it has sometimes a thickness of four or five
lines. It is then white and tough, very much like cartilage,
and is easily separable into many layers. The surrounding
hepatic substance adheres to it closely, and when this is
scraped away, the sac is left hanging on the side towards the
transverse fissure, by fibrous threads, (the remains of obliterated
vessels,) which are lost in its coats. The inner surface of the
sac is generally rough and fretted, and often presents, here and
there, yellowish spots, which, to the naked eye, are very like the
yellow spots so frequently found on the inner surface of arteries.
The membranous bladder, or aceplialocyst, by which the sac is
in all cases closely lined, is not adherent, and may be readily
drawn out by the forceps. Its coats, which are friable, and ol
the firmness of hardened white of egg, are very finely laminated.
STRUCTURE.
337
The layers are, indeed, far too fine to he seen by the naked eye,
or even by low powers of the microscope.
Nothing varies more than the fertility, if so it may be termed,
of acephalocysts. Sometimes, and it is almost always so in the
hydatid tumors of the lower animals, the cyst which lines the sac
contains no floating hydatids ; in other cases, even of long
standing, it contains only a few, perhaps eight or ten ; while, now
and then, it is literally crammed with them, and these, again, may,
it is said, contain another generation.
When the floating acephalocysts have plenty of room, they are
all globes or spheroids ; but when closely packed, they assume
various other forms, in consequence of their mutual pressure.
The floating hydatids have a uniform smooth surface, and are
very finely laminated, but they exhibit no vessels, nor any appa-
rent structure, under the highest powers of the microscope. Their
membrane is elastic, and when punctured contracts, so as to spurt
out the fluid it contains. It breaks down readily under the
finger, like coagulated white of egg. The inner layers are softer
than the outer, and, after death, sometimes separate in flakes, ren-
dering the fluid turbid.
The membrane of acephalocysts is composed of a substance
which is closely allied to albumen. In some of the acephalocysts
which are preserved in the museum of King’s College, numerous
crystals or amorphous masses are seen under the microscope,
which are soluble in acetic acid, and which seem to be composed
of phosphate of lime.
The liquid of acephalocysts has a specific gravity from about
]-008 to 1'013, is neutral or slightly alkaline, as tested by litmus
or turmeric paper, and has a salt taste. It contains common
salt in large quantity ; extractive or animal matter, in an unde-
fined form, in much smaller proportion ; and a trace of other
saline matters — probably, all the salts of the blood which are not
associated with its albumen. It contains no albumen, or only a
faint trace of it, and no phosphates. It shows nothing under the
microscope, but when a drop of it is slowly evaporated on a plate
of glass, beautiful, colourless, microscopic crystals of muriate of
soda are left.
The question has long engaged the attention of pathologists —
What is the nature of hydatid tumors, and how do they originate ?
338
HYDATID TUMORS OF THE LIVER.
By some, acephalocysts have been supposed to he true parasites,
having independent vitality, and propagated by germs intro-
duced from without. By others, they have been supposed to
result from depraved nutrition of one of the normal constituents
of the body. A few years ago, this latter opinion was expressed
in more definite terms by the most eminent of our anato-
mists, # who imagined them to result simply from unnatural
development of the nucleated cells, which perform such an impor-
tant part in the nutrition and growth of all organised bodies.
The question seems at length in the way of being settled by
the interesting discovery, to which attention has lately been re-
called by a French physician, M. Livois, that acephalocysts are
the dwelling-place of those microscopic animacules, to which
Eudolphi gave the name echinococcus, from the cylinder of hooks
which surrounds the head. It has long been known that echino-
cocci occasionally exist in countless numbers in acephalocysts,
hut such instances have been considered exceptional, and the
echinococci have been regarded as parasites of the hydatids.
The researches of M. Livois, f however, have led him to the con-
clusion, that echinococci exist in all acephalocysts. He states
that among more than eight hundred hydatids from man and
other animals, he did not meet with a single one without
them. In order to satisfy myself of the correctness of these
observations, I opened seven of the preparations of hydatids
in the museum of King’s College, and obtained the assistance
of Mr. Busk in examining them. In five of these we had no
difficulty in finding echinococci, or some of their remains, in
the acephalocysts. In one of these preparations, in which the
acephalocysts were a good deal decayed, only the hooks of
echinococci were seen, which, like the teeth and hones of larger
animals, remain when the other tissues are destroyed. In two
of the preparations, no echinococci were found, hut their
absence could be explained from the state of the acephalocysts.
One of these preparations contained several hydatids, which had
been expectorated, and were all broken ; the other contained an
* See Owen’s Lectures on the Comparative Anatomy and Physiology of
the Invertebrate Animals, p. 44.
t Recherche8 sur les Echinocoques, chez l’homme et cliez les animaux.
Paris, 1843.
ECHINOCOCCI.
339
immense solitary acephalocyst, which was turned inside out. It
is possible that in these two instances, all the echinococci escaped
on the rupture or inversion of the cysts, or that they were after-
wards washed away. I examined, besides, great numbers of hy-
datid tumors in the livers of sheep, and only failed to discover
echinococci in one or two instances.
When an acephalocyst quite fresh is opened, its inner surface
may often be seen to he covered with particles of an opaque white,
which are just visible to the naked eye, and which look like very
diminutive fish-spawn. These particles are often not adherent to
the cyst, and may be readily detached by a slight shake of the
fluid. Sometimes they escape in great numbers in the fluid
which spurts out when the cyst is punctured. Under the micro-
scope they are found to he echinococci.
fig. 14.
(V
Echinococci are oval, transparent, colourless creatures, some-
what egg-shaped, and presenting, under the microscope, a distinct
double outline, as represented in Fig. 14. The anterior end (a)
has a depression or cleft, from which there is an evident canal or
mouth, leading to a circlet of hooks which is within the body,
and nearer the posterior end than the anterior. ( c ) represents one
of the hooks or teeth, more highly magnified. The posterior end
(b) has also a slight depression, which has now and then a fibrous
pedicle attached to it.
The creature is studded with globular bodies, which, from their
refracting light strongly, have, under the microscope, a strong
z 2
340
HYDATID TUMORS OF THE LIVER.
dark outline ancl a bright centre. They seem to be in the mem-
brane of which the body is composed, or rather between the outer
membrane and an interior solid body, and are at different depths
from the object-glass, so that, while some are clear under the mi-
croscope, others are indistinct.
Commencing decomposition causes the circlet of hooks to pro-
fig. 15.
a
trade, and the creature has then the form represented in Fig.
1-5, or one much more elongated. It is probable that the living
animal has the power of protruding its head, but fresh specimens
have almost invariably the circlet of hooks within the body.
Most writers who have described echinococci, state that when
the head is protruded, four suckers may be seen just below the
circlet of hooks ; but these suckers have not been visible in any
specimens which I have examined, whether taken from human
hydatids, or from those of the sheep.
With echinococci, as just described, there are generally seen a
few other bodies, which are about half their size, and which have
not the same regular oval form. Their outline is single instead of
double, and they present a confused mass of small granules,
without any of the distinct globules which are seen in the larger
ones. The body, instead of being colourless and transparent, is
yellowish and opaque. The circlet of hooks is visible, but it is
indistinct. These are probably echinococci not yet fully deve-
loped.
In some hydatids the echinococci are not seen as white grains
on the inside of the cyst, and are hardly discoverable by the
naked eye, but they are readily seen when a portion of the cyst
is looked at through the microscope.
ECHINOCOCCI.
341
It was remarked by Laennec, that the echinococci are some-
times agglomerated into small masses of seven or eight, which are
united to each other, and to the inside of the cyst, by a viscid
fluid, and by a membranous film attached to the posterior ex-
tremity of each animalcule. This remark was confirmed by Miiller,
who noticed the appearances described by Laennec, in some
hydatids which had passed through the urethra of a man, and
which came, apparently, from the kidney. M. Livois states that
he never found echinococci so attached, and seems to doubt the
correctness of the observations of Laennec and Muller. In the spring
of last year, Mr. Busk noticed and showed me echinococci thus ag-
glomerated and attached, in an hydatid tumor of the sheep, which
he wras kind enough to examine at my request. The animalcules
were in small globular masses, which were enclosed in a very thin
membrane, and were connected with the hydatid cyst by a short,
indistinct, fibrous pedicle, as shown in ( b ), figure 16 ; in which ( a )
represents a portion of the hydatid cyst. ( c ), in the same figure,
represents one of these globular bodies, partially broken down, and
shows that each individual animalcule has a distinct pedicle.
FIG. 10. FIG. 17.
Fig. 17 represents a portion of one of the masses more highly
magnified, and shows more distinctly the mutual connexion of the
echinococci. The animalcules in each mass arc of the two kinds
(d, e,) described above.
The question presents itself here — What relation have these ani-
342
HYDATID TUMORS OF THE LIVER.
malcules to the aceplialocysts ? They are, without doubt, closely
related to them in some way or other, and are an essential part of
hydatid tumors. In the livers of sheep which are infested with
hydatids, many minute pearly spots may sometimes be seen, which
are too small to be recognised by the eye as hydatid tumors, hut
which, on being crushed, are found to contain echinococci as
large and as perfect as those in the large hydatids. It may he
supposed that the acephalocyst is the mere nidus of the echino-
cocci, and that it is formed by them. But if this be so, how is it
that some hydatid tumors contain many floating acephalocysts,
while others, which are of equal size, and are studded with echi-
nococci, contain none ? How is it, again, that hydatid tumors in
sheep, which are inhabited by echinococci, apparently identical
with those of man, never contain floating acephalocysts ?
Another supposition, which has been advanced by Mr. Busk, is,
that these animalcules, like many others in the lower classes of
animals, and like many plants, propagate in two ways — namely,
by gemmation or buds, and also by seeds or eggs, which are the
echinococci.*
The sac that contains the acephalocysts, as before remarked,
increases in thickness with the size and age of the tumor, but it
often undergoes other changes. The most common of these arises
from the deposit of calcareous matter (phosphate of lime, with a
little carbonate,) in its coats, so as to form ossific plates, like
those so often found on the inner surface of arteries. This
deposit of calcareous matter in its coats, and its ready division into
laminae, establish a striking distinction between the sac of an hy-
datid tumor in the liver and the cyst of an hepatic abscess. How-
ever old or large an abscess he, its cyst is always composed of
dense fibrous tissue, not divisible into laminae, and never containing
calcareous matter in the form of deposit. The sac of an hydatid
tumor, on the contrary, is readily divisible into distinct laminae,
and, when large and of long standing, almost always contains some
ossific plates and calcareous matter in detached grains in its coats.
* A very elaborate paper on the structure and development of echinococci,
which will probably remove some of the difficulties noticed in the text, lias
been lately read to the Medico-Chirurgical Society, hy Mr. Erasmus Wilson.
The paper will doubtless appear in the forthcoming volume of the Society’s
transactions. Another paper, “ on the development of echinococci,” has
lately been read by Mr. Busk to the Microscopic Society.
EFFECTS.
343
Sometimes, this calcareous matter is in such quantity, that the en-
tire sac is converted into an osseous cyst. In the museum of
King’s College, (Prep. 332,) there is a liver containing three large
hydatid cysts, whose walls have all undergone this change.
It is probable that earthy matter is most apt to be deposited in
the coats of hydatid cysts in aged persons. In the Edinburgh
Medical and Surgical Journal, for October 1835, (p. 286,) the
case of a lady is related, who died at the age of 73. Two hydatid
tumors were found in the liver, whose sacs were almost completely
osseous, and which contained a thick gelatinous matter, and nu-
merous hydatids. It appeared probable, from the symptoms, that
the tumors had existed from her eighth year.
It has been remarked by Cruveilhier, that when earthy matter
has been thus deposited, and ossific plates are formed, the inner
surface of the sac has a striking resemblance to that of a true
aneurysm, (an aneurysm without rupture of the coats of the
artery,) empty of clots. The walls of the hydatid sac, like the
walls of an aneurysm, may he ulcerated from distension; perfora-
tion may take place ; and the contents of the sac be effused into
the cavity of the peritoneum ; or, if the ulceration be at a part of the
sac which is imbedded in the liver, the sac may become dilated at
this part into a pouch, which may at length hurst. Not unfre-
quently the process of ulceration causes an opening from the sac
into the gall-bladder, or into one of the ducts.
These changes seem to be the natural consequences of the pecu-
liar organisation of the sac. They occur in hydatid tumors of
the spleen as well as in those of the liver. But in some cases
other changes are met with, which are produced by inflammation
set up within the sac, or in the tissue around it. In what may be
called the healthy state of an hydatid tumor, and in almost all re-
cent tumors of this kind, there are no marks of inflammation about
the sac, and the hepatic tissue immediately surrounding it has its
natural texture, or exhibits only such changes from the natural
texture as are produced by pressure. But, after a time, adhesive
inflammation is generally set up around the sac, and coagulable
lymph is poured out, which glues the sac where it projects above
the surface of the liver, to the parts — the diaphragm, the walls of
the belly, the intestine — with which it happens to be in contact.
Old hydatid tumors of the liver, which project above its surface,
are generally found united by false membrane to contiguous parts.
344
HYDATID TUMORS OF THE LIVER.
Another frequent and more serious change results from suppu-
rative inflammation of the inner surface of the sac, converting it
into an abscess. Andral, Cruveilhier, and most writers who have
published a series of cases of hydatids of the liver, have given
instances in which this has occurred. A great number of others
are scattered through our medical journals, and one instance of
the hind has fallen under my own notice. In such cases, the
hydatid sac contains pus, and fragments of hydatids. When the
patient dies soon after the occurrence of suppuration, some hydatids
are occasionally found entire, and containing a perfectly limpid
fluid, although the fluid in which they float is purulent. Only the
sac is nourished by blood-vessels, and capable of secreting pus. This
cannot be formed by the floating acephalocysts. When the patient
lives long after suppuration has occurred in the sac, it is sometimes
difficult to discover and identify the fragments of hydatids, hut
even then the nature of the tumor may be at once told from the
character of the sac, which differs essentially from the cyst of an
ordinary hepatic abscess, in not adhering so firmly to the hepatic
tissue around it, in being readily divisible into layers, and fre-
quently in containing plates or palpable grains of calcareous matter
in its coats.
Cruveilhier has made the important remark that, while the fluid
in hydatid cysts, in what may be termed their healthy state, is
perfectly limpid and colourless, that in hydatid tumors of the liver
which have suppurated is almost always more or less tinged with
bile. He believes that the entrance of bile into the sac, through
ulceration of a branch of the hepatic duct imbedded in its walls,
is the most common cause of the suppurative inflammation
that converts it into an abscess. I have no doubt of the correct-
ness of this opinion. The greenish colour of the contents of the
sac can only be ascribed to the presence of bile, for no such
colour has been noticed in hydatid tumors in other parts of the
body ; and the presence of bile, (which, when applied to serous
membranes, excites the most intense inflammation,) is a suffi-
cient cause for the suppuration of the inner surface of the sac.
This circumstance explains how it happens that hydatid tumors
suppurate so much more frequently in the liver than in any other
organ. Suppurative inflammation of the sac may, however, be
also excited by other agencies. Andral has related a case (Clin.
Med. iv. p. 485,) in which suppuration of the sac occurred with-
EFFECTS.
345
out obvious cause, and where, after death, the pus was found to be
white and creamy. He has also related another case, (Clin. Med.
ii. p. 408,) in which pus was found in an hydatid sac in the lung,
while the floating aceplialocysts contained fluid as transparent as
rock water. Cruveilhier states* that he has found pus and frag-
ments of hydatids in an hydatid tumor of the spleen. f
Inflammation, whether adhesive or suppurative, seldom occurs
either around or within the sac of an hydatid tumor, until this has
attained a certain age. It rarely happens that any traces of it are
found in hydatid tumors in sheep, whose allotted duration of life,
in their domesticated state, is short.
Occasionally, an hydatid tumor in the liver is found filled with
matter of the appearance of glazier’s putty, or plaster, with
fragments of dead hydatids. This matter, which may accumulate
either between the sac and the acephalocyst which lines it, or
within this acephalocyst, is composed chiefly of phosphate of lime,
and of animal matter allied to albumen. It contains also a small
quantity of carbonate of lime, and in some cases, if not in all, a
small quantity of cholesterine. Two cases of tins kind have fallen
under my own observation during the past year, and many
others have been collected by Cruveilhier, who rightly considers
the secretion of a thick matter from the inner surface of the sac, to
be one mode of cure of hydatid tumors. Tumors containing such
matter generally look as if they had been at some former time
much larger. In some instances no fragments of hydatids, which
can be recognised as such, are to be found, and the nature of the
tumor can only he inferred from the peculiar characters of the sac.
Similar changes occasionally take place in the contents of
hydatid tumors in other organs. In the following case, which I
have taken from Cruveilhier, an hydatid sac in the spleen contained
a matter like plaster or cheese, while another hydatid sac in the
liver contained pus.
Case. A day-labourer, set. forty-si5c, of a large powerful frame, and good
* Diet, de Med. et Chirurgie pratiques. Art. “ Aeephalocyste/’ p. 244.
t The explanation of some of these cases is, perhaps, that a part of the
sac imbedded in the organ became perforated from ulceration ; that some of
the fluid which the tumor originally contained escaped into the surrounding
areolar tissue, and excited suppurative inflammation ; and that some of the
pus there formed got into the sac, and set up suppurative inflammation of
its inner surface.
346
HYDATID TUMORS OF THE LIVER.
constitution, was admitted into the hospital (of Dijon) in January, 1839. He
stated that for eighteen months he had suffered from tertian ague, which had
deprived him of the robust health which he before enjoyed; that this ague
lasted two months, and afterwards recurred at different intervals ; and that
from its first occurrence he had constantly felt in the upper zone of the belly,
an impediment, rather than a pain, which now and then deranged digestion,
and rendered him less fit for hard work or long walks. Sometimes he had
been obliged to give up for a time his fatiguing occupations, but he worked
until six weeks before his admission to the hospital. He lived a month after
admission, and during that time presented the following symptoms :
Face thin, complexion pale and a little yellow, thirst, bad taste in the
mouth, white tongue, tension and dulness on percussion, in all the upper
zone of the belly ; belly not painful, bowels confined. Dry cough, oppression
of breathing, stitch of the side at the level of the left mamma, (this symptom
was only of twelve days date,) dulness on percussion over all the left side of
the chest, and over the lower part of the right side, absence of respiratory
murmur on the left side, no aegophony. Respiratory murmur of natural cha-
racter on the right side, but distant and feeble in its lower part, pulse very
frequent, skin hot and dry.
The oppression of breathing increased, the jaundice became well-marked,
and frequent vomiting came on. Soon after, diarrhoea, emaciation, profuse
sweating, hectic fever, general oedema, and finally, death, without marked
pain or any impairment of intellect.
The pleural cavities were filled with yellowish serum, but the heart and the
lungs were sound.
In place of the right lobe of the liver was a large sac filled with very foetid
pus and some hydatids. The left lobe of the liver was enlarged, apparently
from displacement of the substance that originally formed the right lobe, and
which seemed to have been pushed to the left. This sac was lined by a gan-
grenous “ detritus,” of an orange-yellow colour. From its sides hung large
shreds of membrane, many of which presented here and there cartilaginous
and chalky scales. Most of the shreds were still adherent : but some were
completely detached and of the brightest orange-yellow tint. At its upper
part this immense sac communicated by two large openings with a second
cavity situated between the diaphragm and the convex surface of the liver.
This cavity, which likewise contained gangrenous shreds, was on the point
of opening through the diaphragm. Over all the peritoneal surface of the sac,
the liver was firmly united to the diaphragm. On a close examination of the
sac, the right branch of the hepatic duct was found to open into it.
Another hydatid tumor existed in the spleen, projecting from its posterior
surface, which seemed to be moulded on the outer surface of the sac. The
coats of the sac, which were dense and leathery, creaked under the scalpel,
and presented some calcareous scales. The sac contained a large acepha-
locyst, folded up and compressed, and a matter like cheese or plaster, which
adhered to its inner surface and filled up the outer folds of the acephalocyst.
(Anat. Path., liv. 35. pi. 1.)
5
EFFECTS.
347
This case is interesting as exhibiting most of the changes which
are apt to occur in hydatid tumors in the liver : — calcareous
degeneration of the walls of the sac ; irregular dilatation of the
sac, so as to form additional pouches in the substance of the liver ;
perforation of a gall-duct, entrance of bile into the sac, and, conse-
quently, suppurative inflammation of the inner surface of the
sac.
In the hydatid tumor in the spleen, chalky matter was like-
wise deposited in the coats of the sac, and matter of the same
kind was secreted from its inner surface. Cruveilhier supposes
the secretion of this matter in hydatid tumors to he consequent
on the death of the hydatids. It is perhaps just as likely that it
is the primary change, and that it destroys the hydatids and the
microscopic animalcules that so constantly inhabit them.
There is still another source of danger from hydatid tumors
in the liver. They are apt to burst, either from blows or acci-
dental pressure, or from ulceration, and to discharge their contents
into the cavity of the peritoneum. From the nature of the fluid
in healthy hydatid cysts, it might be imagined that their bursting
into this cavity would excite no inflammation, and would he at-
tended with little danger. But experience has proved the con-
trary. The fluid in hydatid cysts, although so limpid and colour-
less, is a violent irritant for the peritoneum, always exciting the
most intense inflammation of it. Cruveilhier imagined that the
inflammation might result from some of the hydatids escaping
from the sac and irritating mechanically the surface of the serous
membrane ; hut the same thing happens from the bursting of a
solitary hydatid cyst. The bursting of an hydatid cyst, whether it
contain floating hydatids or not, and when the liquid only of the
cyst escapes into the cavity of the peritoneum, excites intense in-
flammation of that membrane, and may destroy life as soon as the
bursting of the gall-bladder or of an hepatic abscess. Cruveilhier,
in the paper already referred to, (Diet, de Med. et Chir. Prac-
tiques. Art. Acephalocyste,) has collected from various sources
four cases (obs. 6, 7, 8, 9,) in which the patients died very
rapidly, with the symptoms of peritonitis from perforation of the
bowel, from the accidental rupture of an hydatid cyst in the liver ;
and two cases of the same kind are related by Mr. Csesar Hawkins
in the eighteenth volume of the Medico- Chirurgical Transactions,
348
HYDATID TUMORS OF THE LIVER.
(p. 124 and p. 12G). In three of these six cases (Cruv. obs. G,
8, 9,) the sac contained many hydatids ; in the other three the
aceplialocyst was solitary, and nothing but the fluid it contained
and echinococci, could have escaped into the cavity of the perito-
neum. From these cases and from others of the same kind, it
would seem that the bursting of an hydatid tumor into the sac
of the peritoneum, causes death as surely, and just as speedily,
as the bursting of an abscess, or as perforation of the stomach or
bowel. Mr. Hawkins, in the paper already cited, has related
some other cases in which the fluid of hydatid cysts in the breast
and other parts, seemed to be very irritating, causing sloughing
and fungoid ulceration.
From the apparently simple constitution of a fluid, and from its
harmlessness when applied to one tissue, we must not infer its harm-
lessness when applied to other tissues overwhich it is not destined to
pass. Atmospheric air, which seems to be so bland, and which is in
healthy relation to the skin and to large tracts of mucous membrane,
is a most violent irritant to the serous covering of the lungs.
A very important point in the history of hydatid tumors of the
liver, is that very often more than one such tumor is found in
the same person. Sometimes, the liver itself contains two hydatid
tumors ; and some rare instances are recorded in which it con-
tained three or more. It has been remarked that in such cases
the tumors generally contain, each, only a single acephalocyst.
But sometimes, with a single hydatid tumor in the liver, an
hydatid tumor is found in the lower lobe of one of the lungs or
in the lower lobe of each lung. An instance of this kind is cited
by Mr. Hawkins in his paper in the eighteenth volume of the
Medico- Chirurgical Transactions. There was a solitary hydatid
in the liver, and one in the lower part of each lung. Another in-
stance is cited by Cruveilhier, (Op. cit. p. 245,) in which there was
a multiple hydatid in the liver, and a solitary hydatid of enormous
size in the lower lobe of each lung. Another instance is recorded
by Andral, (Clin. Med. ii. p. 408,) in which, with a solitary hyda-
tid in the liver, there was a solitary hydatid in the lower lobe of
the left lung.
I am indebted to Dr. Watts, of Manchester, for details of a case
that fell under Ins care, in which, with a solitary hydatid in the
liver, there was a solitary hydatid in the lower lobe of the left
lung.
EFFECTS.
349
The patient, a factory-man, forty-seven years of age, had good health till
the beginning of the year 1842, when he became dyspeptic, complaining of
pain in the stomach, and in the back, below the right shoulder-blade. In the
month of April of that year, he was treated by Dr. Williams for inflammation
of the left lung. He recovered from this, but the pain in the stomach and
in the back continued, and he was not able to resume his work in the factory.
On the 12th of April, 1843, he was taken extremely ill, with increase of pain
at the stomach, together with acid eructations and with great weakness.
This was followed by difficulty of breathing, and at length by symptoms of
gangrene of the lung, and he died at the end of a fortnight.
On examination of the body, the liver appeared to be very large, but this
was owing to an hydatid tumor, as large as a child’s head, which was im-
bedded in its substance, and which contained a solitary acephalocyst. The
cyst was green from the imbibition of bile, and contained a green and turbid
fluid.
In the middle of the lower lobe of the left lung was another hydatid tumor,
of the size of a large fist, and, like that in the liver, containing a solitary ace-
phalocyst. The lower lobe of both lungs, but especially of the left, was solid
but easily broken down between the fingers, giving escape to a thick opaque
matter, which had a most disgusting smell of gangrene.
The cysts were presented by Dr. Watts to the museum of King’s College.
Hydatid tumors in the lung differ from those in the liver, only
in the sac being thinner. In all the instances which I have found
recorded, they have been in the lower lobes of the lungs. Owing
perhaps to the thinness of the sac and to the compressibility of
the lung, they sometimes attain an enormous size, almost filling
the chest, and causing death by suffocation.
Hydatid tumors are sometimes formed in the lower lobes of the
lung, when there are no such tumors in the liver or in any other
organ. Andral has related two cases of this land, (Clin. Med. ii.
p. 407 & 410); and several others have been collected by Cru
veilhier.
It appears from these cases that hydatid tumors may form
primarily in the lung, as well as in the liver, hut when, as in the
case just referred to, an hydatid tumor is found in both organs at
once, we must — if we consider how few people comparatively have
an hydatid tumor in either organ — admit that the two tumors arc
related, either by their dependence on a common cause, or by the
dependence of one tumor on the other. If we adopt the latter
hypothesis, which circumstances, to be presently mentioned, ren-
ders the more probable one, and if we consider that in man single
350
HYDATID TUMORS OF THE LIVER.
hydatid tumors are much more frequent in the liver than in the
lung, we shall be led to infer that in the great majority of cases
in which an hydatid tumor in the lung is associated with one in
the liver, the former is the offspring of the latter. We have seen
that by ulceration of the inner surface of an hydatid sac in the
liver, the gall-ducts that adhere to its walls may become perforated,
and bile may flow into the sac, or, conversely, the contents of the
sac may escape into the gall-ducts. The blood-vessels may pro-
bably be opened by ulceration in the same way. If now a germ
of an acephalocyst or echinococcus should enter one of the hepatic
veins, it might be carried through the heart to the lung, and there
give rise to an hydatid tumor. This hypothesis is in some degree
supported by the following interesting case recorded by Andral.
A man, fifty-five years of age, had all the symptoms of organic disease of
the heart, and died in a state of asphyxia.
Both lungs were filled with a great number of hydatids. Andral first
thought that these were in the substance of the lung, but on careful dissection
he discovered that they were all lodged in the pulmonary veins • He traced
these veins from the heart to the lung, and, on reaching their almost capillary
divisions, he found that many of them presented a great number of pouches
which were formed by dilatation of a portion of the vessel, and which were
filled with hydatids. Beyond each of these dilated portions, the vein regained
its former calibre, and a little farther on became dilated again. The largest
pouches were of the size of a walnut, the smallest scarcely as large as a pea.
The hydatids which they contained had all the characters of acephalocysts.
Many of them exhibited small points of a dead white in their coats ; others a
great number of miliary granulations on their inner surface (which were
doubtless echinococci).
In the middle of the liver, was an hydatid sac, with cartilaginous walls,
capable of holding a large orange, and containing eight or ten acephalocysts.
(Clin. Med. ii. p. 412.)
This case is explained by supposing that hydatid germs from
the liver had got into the hepatic vein, and that being carried to
the capillary branches of the pulmonary veins, they were there
developed and multiplied.
An hydatid tumor of the liver is still more frequently associated
with one in the spleen. An instance of this kind has been al-
ready cited from Cruveilliier. In his article on acephalocysts,
which has been so often referred to, Cruveilliier has given another
EFFECTS.
351
instance (obs. ii.) in which there were two hydatid tumors in the
liver (not said to be multiple), and two in the spleen. Andral
has given an instance in which with a tumor containing floating
hydatids in the liver, there was a similar tumor in the spleen ; and
numerous other cases of the same kind are on record.
An hydatid sac in the spleen undergoes the same changes from
distension, and from the deposit of calcareous matter, as an hyda-
tid sac in the liver, from which it differs only in the greater thin-
ness of its coats ; the consequence, perhaps, of the less degree of
resistance which it experiences in its growth. It is less liable to
suppurate than an hydatid sac in the liver, from not being exposed
to the entrance of bile.
It is an important circumstance that an hydatid tumor of the
spleen, though often associated with one of the liver, is hardly
ever found alone. Another circumstance which serves to throw
light on the origin of such tumors, and which, like the former,
was noticed by Cruveilhier, is that an hydatid tumor is rarely
found in the substance of the spleen. It is almost always on the
posterior surface of the organ, (apparently formed in the gastro-
splenic omentum,) and the spleen is moulded upon it.
Sometimes, with an hydatid tumor of the liver, there is a simi-
lar tumor in some part of the mesentery. Cruveilhier (op. cit.
p. 216) has given the details of a case, recorded by M. Monod,
in which there was a tumor of fifteen years standing, containing
numerous hyatids, in the liver ; another sac of the same kind,
partially imbedded in the spleen ; a third, in the transverse meso-
colon.
Occasionally, with an hydatid tumor of the liver, thousands of
hydatid tumors are found in the belly, under the peritoneum and
between the folds of the mesentery. Cruveilhier (liv. xix. pi.
1 and 2,) has published drawings taken from a case of this kind.
In the midst of the liver was a large sac containing an aceplialocyst, which
had collapsed, and which when filled out was three or four times larger than
it at first appeared. The coats of the sac were very thick, and a gall-duct
opened into it. The sac, on three-fourths of its surface, was invested by the
liver : on the remaining fourth, it was confounded with the walls of a cyst of
the mesentery. There were three other hydatid tumors, not altered, along
the right edge of the liver, and partly sunk into it. The spleen presented
352
HYDATID TUMORS OF THE LIVER.
some superficial hydatid cysts. Between the liver and the spleen, and below
these organs, there was a large globular mass pointed below, and reaching
into the pelvis. This mass, when cut into, presented a number of hydatid
sacs of different dimensions, communicating with each other by circular
openings, of various sizes. The sacs had all a fibrous structure, and con-
tained, some a single hydatid, others two or three, or as many as seven or
eight.
Another case very similar to this is related by Cruveilhier. In
that case —
The liver was very large, filling all the right hypochondrium, the epigas-
trium, and the left hypochondrium ; and the omentum was sprinkled with
cysts, which extended into the pelvis. The liver contained four cysts, the
largest, of the size of an infant’s head. An hydatid cyst in the lesser omen-
tum compressed the spleen. The gastro-hepatic omentum and the great
omentum contained imbedded in them more than fifty hydatid cysts, from
the size of a walnut to that of two fists, and forming a kind of chaplet which
extended from the concave surface of the liver into the pelvis. The cavity of
the pelvis was filled by a large cyst, situated between the rectum and the
bladder, and adhering to the right vesicula seminalis, at the expense of
which it seemed to he formed. (Op. cit. Art. Acephalocyste, p. 226.)
A case of the same kind fell under my charge in King’s College
Hospital, in the autumn of 1842.
Case. — George Berbick was admitted into King’s College Hospital on the
31st of August, 1842. He was 28 years of age, a porter, of temperate habits,
and had always resided in London. He had good health till about ten years
before, when his belly began to enlarge, without his suffering any particular
inconvenience from it, except that ever since he had been “ troubled with
bile.” Five years ago, he had a severe illness, which seems to havebeen typhus
fever, which lasted seven or eight weeks, during part of which he was in
Charing Cross Hospital. He recovered perfectly from this illness, but the
belly continued to increase in size till three years ago, since which, he states,
it has ceased to grow larger. For the last seven years has been subject to
“ spasms,” which of late have been less frequent than formerly. Six weeks
ago, was seized with sore throat and erysipelas of the head which lasted a
fortnight. Since that time has been losing flesh, and has vomited almost
every thing he has taken.
At the time of his admission to the hospital, he was much emaciated, and
his intellect was weak, so that he did not always answer questions pertinently.
He vomited everything he swallowed, and had some diarrhoea. His urine
and fseces were passed in bed. His appetite was bad; his tongue covered
with a dark coat ; his pulse, 84, very weak. The belly was much enlarged,
and the lower part of the chest was greatly expanded. A great number of
hard tumors, about the size of oranges, were felt through the walls of the
belly, but there was no fluctuation. The dulness on percussion over the
EFFECTS.
353
liver extended considerably below the false ribs. Below this in a line ex-
tending nearly across the belly, just above the umbilicus, was the clear
sound of intestine. Over the rest of the belly, percussion produced a sound,
not naturally clear and not altogether dull, giving the idea of a solid layer
beneath the abdominal muscles, and resting on the intestines. The chest
was dull on percussion on the right side as high as the mamma, and on the
left side nearly as high. The heart beat above the left mamma.
He was ordered five grains of sesqui-carbonate of ammonia, and five drops
of tincture of opium, every four hours; and f.jiii. of wine daily.
He gradually sank, and died on the 3rd of September.
The body was examined twenty-four hours after death, and the following
notes of the appearances presented were entered in my case-book, by my
friend and former pupil. Dr. George Johnson.
“ On opening the abdomen, a number of globular tumors were seen con-
nected with the omentum. These proved to be hydatid tumors. Some of
them contained a single acephalocyst, filled with a clear fluid; others con-
tained several hydatids, from two to fifty or more ; and some of them were
quite solid from containing a great number of hydatids from which the
fluid had escaped, and which were closely packed in their investing
cyst, like a number of dried raisins.* The omentum was removed with
these hydatid tumors connected with it, and the intestines beneath were
found to be quite sound. The colon passed across where the line of reso-
nance was observed during life. Some tumors of the same kind were con-
nected with the liver, rendering it of enormous size. The substance of the
liver was quite healthy. Some of the tumors were partly imbedded in it,
and with one of these the gall-bladder communicated. The largest tumor
connected with the liver contained about half a pint of fluid.
“ Some tumors of the same kind were also connected with the spleen; and
one was connected with the summit of the urinary bladder.
“ All the large investing cysts were globular, as were also the contained
hydatids.”
In all such cases, where, with an old hydatid cyst in the liver,
we find an hydatid cyst in the spleen, or in the omentum, and
other cysts between the layers of peritoneum, it seems probable
that the cyst in the liver is usually the parent of all the rest. Their
occurrence in the parts mentioned may he explained in the same
way as the occurrence of cysts in the lungs, by supposing that an
hydatid germ finds its way into one of the small branches of the
portal vein imbedded in the primary hydatid sac ; that this germ
passes backwards in the splenic or mesenteric vein, and there be-
comes developed into hydatid tumors.
* The hydatids seem to be sometimes destroyed by being packed too
closely; or from the containing sac not enlarging sufficiently as they
multiply.
A A
354
HYDATID TUMORS FO THE LIVER.
According to this supposition, an hydatid tumor in the liver
may give rise to secondary hydatid tumors in the lungs, in the
liver itself, or between the folds of mesentery, according as an
hydatid germ finds its way into the hepatic or the portal vein.
This supposition, as to the origin of the secondary hydatid
tumors, explains how it happened that in all cases in which there was
an hydatid tumor in the lung, there was only one hydatid tumor
in the liver, and none in the spleen or in the mesentery ; while
in those cases in which there was more than one hydatid tumor
in the liver, or in which there was an hydatid tumor in the
spleen or in the mesentery, as well as in the liver, there was no
such tumor in the lung. It explains, too, the fact, that with an
hydatid tumor of the liver in man, we seldom, if ever, find
hydatid tumors in other organs, excepting the lungs or the mesen-
tery.
If the presence of more than one hydatid tumor indicated, as
some have supposed, a peculiar or constitutional tendency to
their formation, they would not be thus limited to particular situa-
tions ; hut when several such tumors existed in the liver, or
when the mesentery was studded with them, there would probably
be some likewise in the lung ; when they had formed in the
lungs, we should expect that they would have formed also in the
mesentery, or at least, that there would he more than one hydatid
tumor in the liver.
The constancy with which hydatid tumors in the liver are
associated in one case with hydatid tumors in the lungs only ;
in another, with hydatid tumors in the spleen, or in the mesen-
tery only, strongly favours the supposition, that a tumor of the
liver may, by the escape of germs into a branch of the hepatic or
of the portal vein, or into one of the lymphatics, lead to secon-
dary tumors in the lungs, or in the liver itself, or between the
folds of mesentery. In such cases, too, there is generally one
tumor in the liver, which, from its greater size, from the greater
thickness of its coats, and from other marks of age, looks like
the parent of the rest. In a large proportion of such cases, this
patriarchal looking tumor presents ulceration, or other marks of
disease, on the inner surface of the sac.
It has been just stated that an hydatid tumor of the liver is
associated only with hydatid tumors in the lung, or in the mesen-
tery. There is, however, a remarkable case published by Mr.
EFFECTS.
355
Hill, of Dumfries, (2nd vol. of Medical Commentaries, p. 303,)
in which an hydatid tumor (in the liver ?) in a little girl, burst and
discharged its contents through the walls of the belly. She got
quite well from this ; but, thirteen years afterwards, three large
hydatid tumors which seemed no deeper than the muscles, ap-
peared on different parts of the belly. These tumors burst,
two outwards and one into the intestines, and the patient ulti-
mately recovered.
In this instance, the secondary tumors seemed to be confined
to the walls of the belly, and probably resulted from adhesion
between them and the liver, and the consequent escape of an
hydatid germ into one of the veins of the abdominal muscles.
It is a striking fact that there were no hydatids in the lungs
or in the mesentery, the parts in which they are most frequently
found, when there is an hydatid tumor in the liver.
The greatest objection to the hypothesis here advanced to
account for the tumors in the spleen and mesentery, is the impro-
bability that an hydatid germ should pass backwards into one of
the branches that feed upon the vena portse, against the current
of the portal blood. It seems more natural to suppose that the
tumor in the liver in such cases is secondary to those of the
spleen or mesentery, and not the origin of them. A strong fact
against this latter hypothesis is the appearance of greater age
in the tumor in the liver in such cases, and the circumstance
that while hydatid tumors in the liver alone are not uncommon,
it seldom, if indeed ever, happens that hydatid tumors exist
alone in the spleen or in the mesentery.
The list of evils that may result from an hydatid tumor in the
liver has not been yet gone through. The pus that may be
formed within it, or the proper fluid of the cyst, which, to the
peritoneum, at least, is, as we have seen, just as irritating as pus,
may become extravasated into the surrounding hepatic tissue,
or it may find its way into the veins or excite inflammation of
a vein, and so lead to suppurative inflammation in another part
of the liver, or to inflammation of both lungs.
In the following case, for which I am indebted to Mr. Bowman,
an hydatid tumor of the liver, besides producing other evils, led
to disorganisation of the surrounding hepatic tissue, to the
formation of an abscess in a remote part of the liver, to suppura-
tive inflammation of the hepatic veins, and to inflammation of
A A 2
35(5
HYDATID TUMORS OF THE LIVER.
the lower lobes of both lungs. The case is very long ; but it is
drawn up so admirably, and presents so many points of interest,
that I have not ventured to abridge it.
Case. — “ Judith Austin, a servant girl, set. twenty-five, was admitted
into the hospital (Birmingham) on the 24th of February, 1837. According to
her own account and that of her friends, she had enjoyed uninterrupted health
up to the Christmas preceding, when, without obvious cause, she was seized
with shivering and other febrile symptoms, together with pain in the region
of the liver, which was followed after a few days by jaundice. Her dis-
ease was considered to be inflammation of the fiver. Leeches and blisters
were applied, she was bled from the arm, and her mouth was slightly
touched by mercury. Under this treatment she seemed to have recovered,
and accordingly returned to her place of service ; still, however, feeling an
uneasiness in her side, and complaining of lassitude and weakness. She
had scarcely been at her work a week when she was seized suddenly with
a rigor, which was followed by heat of skin and perspiration. On the
following morning, three days before her admission to the hospital, she
found herself jaundiced.
When brought to the hospital, the jaundice was rather deep, and was
attended with itching, particularly at night, and with occasional cramps of
the limbs. The skin was rather dry and scurfy, of natural temperature.
The pulse slightly accelerated. Respiration natural, without cough. Appe-
tite bad. Slight thirst. Tongue foul. Occasional sickness. Headache.
Bowels much constipated. Stools of a fight brown colour. Urine of a
deep yellow, tinging the linen, and turning to an olive-green on the addition
of muriatic acid. She complained of uneasiness in the right hypo-
chondrium, especially on moving, or on lying on the left side. Wheu in
the last named posture, she felt a weight dragging from the right side of
the belly, and sometimes had nausea ; and she always rested on the right
side or back. She had likewise at times an aching pain in the right shoulder.
On examination, there was found to be considerable fulness and firm swell-
ing, extending from under the cartilages of the ribs on the right side and
from the ensiform cartilage, as low down as the umbilicus. As far as could
be ascertained, the swelling was of uniform surface, and unyielding. When
firm pressure was made upon it, she complained of some pain. The swell-
ing gave out an entirely fiat sound on percussion. The rest of the abdomen
was tympanitic. Her face was rather pale, and her appearance, independ-
ently of the jaundice, was that of a person considerably out of health. The
catamenia were regular. A dose of blue pill and colocynth was given every
night, which kept up a gentle action of the bowels, and the jaundice grew
fainter.
On the 4th of March, she complained of increased pain in the right side,
and a blister was applied there in consequence. The blister rose well, but
the pain was not relieved.
On the morning of the 8th, she had a slight rigor, with headache, and
EFFECTS.
357
thirst, and nausea ; and an erysipelatous inflammation appeared around the
vesication. (Tartar emetic was ordered in doses of three-fourths of a grain,
every second hour, until it should produce vomiting.)
On the 9th, the erysipelas had extended upwards towards the axilla, and
vesications had begun to appear on the surface first affected. She had less
thirst, and no nausea. The tongue was covered with a yellowish fur ; the
pulse 88, and soft. (Small doses of tartar emetic and of liquor ammonise
acetatis were given in camphor mixture ; and a spirit lotion was applied to
the side-)
On the 11th, the erysipelas had passed away, and the cuticle was desqua-
mating. The stools contained bile, and the jaundice had almost entirely
disappeared ; but the urine was still deeply tinged. The countenance, how-
ever, was very sensibly changed, being now thin and pale, and the strength
was materially reduced. There was no abatement of the swelling in the
hypochondrium, but the tenderness had subsided. (Small doses of sul-
phate of quinine, with spir. aether nitrici, were ordered ; and two glasses of
wine were allowed daily.)
From this time the tumor grew rapidly larger, and towards the latter end
of the month it again became very tender. She also suffered from frequent
vomiting, and continued to do so up to the time of her death. On the 23rd,
and again on the 26th of March, she had a severe and prolonged rigor.
This did not immediately recur but the hectic fever continued, with re-
peated vomiting, and with much pain in the right hypochondrium.
On the 5th of April, the tenderness over the tumor had increased, and
there was a superficial rounded prominence between the cartilages and the
umbilicus. The jaundice had quite disappeared. The urine threw down
a pink sediment.
On the 9th of April, she had another rigor, which lasted two hours,
followed by increased heat of skin, but only by very slight sweating. Per-
cussion over the tumor gave an indistinct sense of fluctuation.
The tumor now became more prominent, and the sense of fluctuation
more distinct. The bowels were costive and rather tympanitic ; and the
pain which she had before felt in the right shoulder, was much aggra-
vated.
She gradually sank, and died on the 1 2th.
The body was examined twenty hours after death.
The liver was found to be exceedingly enlarged, reaching as low down
as the umbilicus and into the left hypochondrium. It was adherent by
recently effused lymph to a great part of the diaphragm, to the walls of the
belly, to the extreme right of the transverse colon, and to the right kidney.
These recent adhesions having been separated by passing the finger between
the contiguous surfaces, a portion of the convex surface of the liver, as large
as the palm of the hand, was found to be so firmly united to the diaphragm,
under cover of the cartilages, that it could not be detached. To the feel,
the whole of the right lobe seemed to be little more than a great bag of
fluid, although a considerable quantity of healthy structure remained to-
wards the left. On a puncture being made, the nature of the disease was
358
HYDATID TUMORS OF THE LIVER.
apparent. The contents consisted of more than three pints of a thinnish
opaque liquid, which was deeply coloured by bile, and contained pus in the
proportion of about one-third, and in which floated a great number of
hydatids of various sizes, some being as large as pullets’ eggs, while others
were no bigger than peas. The larger ones were collapsed bags, more or
less transparent, some containing within them similar collapsed cysts, others
a gelatinous matter only, and others, merely a serous fluid.
The great cavity in which these were contained, was lined by a dense
whitish membrane, an eighth of an inch thick, crossed in various directions
by prominent branching lines, which were themselves intersected almost
at right angles by others, covered with an irregular coating of soft lymph,
coloured by pus and bile. These bands, which were all found to be imper-
vious, were the remains of distended vessels. On the posterior part of the
inner surface of the sac, there were the remains of a very thick cartilaginous
cyst, which presented some calcareous plates, and was deeply stained by
bile. There could be no doubt that this was an old cyst in which the
hydatids had been first contained. Several of the biliary ducts emptied
themselves into the cavity; but the most remarkable circumstance was
that the gall-bladder itself communicated with it, and contained, instead
of bile, a number of hydatids floating in a gruel-like fluid. The opening
into the gall-bladder was circular, about the size of a writing quill, and
situated near the duct. The hydatids in the bladder were too large to pass
through this opening, one of them being of the size of a filbert and well
distended. They were all globular cysts, and appeared more delicate than
those in the large cavity. The mucous membrane of the gall-bladder was
pale and healthy, even to the edges of the aperture. The cystic duct was
not coloured by bile, but had a free communication with the common duct.
Phis and the hepatic ducts were healthy, and discharged themselves as
asual. .
On the outside of this immense cyst, the hepatic structure was in very
different states in different parts. In some parts it was redder than natural
and compressed; in others, it was pale and soft; while in one large por-
tion it was disorganised to a great depth, — of a light brown colour, and fetid
smell. The parenchyma was there almost destroyed, nothing remaining
but cellular flocculi and the half-dissolved branches of vessels. The tissue
of the organ generally was pale and softer than it should be.
In the left lobe, close to the convex surface which adhered to the dia-
phragm, there was an abscess, of the size of a walnut, bounded by a thick
membrane containing nothing but pus. This abscess was contiguous to
one of the hepatic veins with which it communicated by an opening large
enough to admit a writing quill. That part of the vessel which thus com-
municated with the abscess contained pus. The pus was confined on all
sides by lymph, which, after lining the sides of the vessel, passed off from
them towards the vena cava, in the shape of a long conical tube, the cavity
of whic h was thus continuous with that of the abscess. At the other ex-
tremity, the lymph quite plugged up the vessel for some distance, but many
of its branches in the left lobe contained small collections of pus circum-
scribed by lymph.
6
CAUSES.
359
In slicing the organ in different directions, small spots were divided, which
were of a bright green, apparently from the extravasation of a small quan-
tity of bile from inflamed and ulcerated ducts. From some of them a little
pus, as well as bile, could he squeezed.
All the branches of the portal vein were sound.
The liver covered the stomach, but was not adherent to it. This viscus
was of natural size. Its mucous membrane was pale throughout, and
towards the cardia considerably softened ; so that a gentle pressure of the
nail was sufEcient to tear it up.
The rest of the alimentary canal was quite sound. The contents of the
intestines had the usual admixture of bile, but no hydatids were found
among them. The spleen was rather large but healthy. The kidneys
and the urinary bladder were natural. The uterine organs presented marks
of former pregnancy, but nothing worthy of notice. The pelvis contained
about a pint of serous fluid, without flocculi.
The lungs were nowhere attached to the ribs. The lower lobe of the
left lung was dense and heavy and of a dark colour, and it did not crepi-
tate. When cut into, it was found to be gorged with bloody serum, and in
many parts to be of a yellowish or grey colour. In all these parts the
tissue of the organ was very soft, the slightest pressure of the finger being
sufficient to break it down. The mucous membrane of the bronchi was
here and there more vascular than natural, and was everywhere covered
by a somewhat viscid mucus. The remainder of this lung was healthy.
The right lung was in a similar condition to tho left, except that its
lower lobe was simply gorged with bloody serum and much condensed.
The morbid appearances were as marked in front as behind.
The pericardium contained about two ounces of clear serous fluid. The
heart was of natural size and structure.
The brain was firm and healthy.
From the peculiar structure of hydatid cysts, and from the pe-
culiar character of the fluid they contain, as well as from the fact
discovered by M. Livois, that they are almost invariably inhabited
by echinococci, no doubt can remain, that they are true parasitic
growths ; and that the proximate cause of their formation is the
introduction of one or more germs of the parasites into the body
under conditions favourable to their development. Many circum-
stances, such as age and condition of life, may be very important,
but merely as favouring or not tbe introduction of the germs of
the parasites into the body and tbeir subsequent development.
From the cases which have been placed on record, hydatid
tumors seem to be of nearly equal frequency in the two sexes.
They are most common in persons from the age of 20 to that of
40, but may occur at any age from 0 years to 50.
360
HYDATID TUMORS OF THE LIVER.
I have found no instance recorded in which such a tumor oc-
curred under the age of 5 or 6, or above that of 52. Cruveilhier
(op. cit. p. 216) has related the case of a man who died at the
age of 77, with an hydatid tumor of the liver, which appeared 15
years before, — that is, when he was 52. In all the other cases
which he collected, and which are twenty in number, the tumor
seems to have formed under the age of 40.
Hydatids are met with in all conditions of life, hut seem to he
more frequent among the poor than among the rich.
Of the published cases of hydatids of the liver, there is a con-
siderable proportion in which the tumor seems to have formed
soon after a blow on the side, and, as was supposed, in conse-
quence of it. Among the cases collected by Cruveilhier there are
four in which the tumor was supposed to originate in this way ;
and in the paper by Mr. Csesar Hawkins, in the eighteenth volume
of the Medico-Chirurgical Transactions, there are several others
in which the tumor seemed to he the effect of some injury done to
the side.
In some instances in which the disease was ascribed to a blow,
the tumor contained a solitary acephalocyst ; in others many.
In some there was only one tumor ; in others, more than one
tumor in the livei’, or a tumor in the spleen as well.
This circumstance throws discredit on the imputed cause ; or
is an additional argument in favour of the doctrine that in cases
in which there are many hydatid tumors in the same person, one
of those tumors is often the parent of the rest.
Hydatid tumors, of essentially the same character as those of
the liver, have been found in man in other organs besides the
liver, the lungs, the spleen, and the mesentery. They have been
met with, but in comparatively very few instances, in the kidney,
in the brain, in the spinal canal, in the thyroid gland, in the sub-
cutaneous areolar tissue ; and in one instance, (Livois, p. 117,)
in the globe of the eye behind the crystalline lens. In almost all
such instances on record, there has been only one hydatid
tumor in the body.
Hydatid tumors, which, like those of man, contain echino-
cocci, are, as already remarked, very common in this country in
sheep, and they have been found in most other herbivorous
mammalia, but not in animals of any other class. The echino-
cocci of sheep are exactly like those of man, but the hydatid
CAUSES.
3G1
tumors are in many respects different. They are not regularly
globular, as in man, and never contain more than a single ace-
phalocyst ; # but, as if to make up for this, there are generally a
great number of tumors in the same animal. Hydatid tumors
in the sheep, as in man, are most common in the liver, which
is sometimes found studded with them, when there are none in
other organs. Often, however, the lungs are studded with
them, as well as the liver ; and now and then, as in man,
there are great numbers in the peritoneum. f In sheep, hydatids,
like flukes, are endemic. If one sheep in a flock has them, all
the others have them more or less. The disease has been re-
marked to be especially frequent in unusually wet seasons ; and
in ill-drained pastures. All these circumstances would lead us to
expect that hydatid tumors in man would prevail in particular dis-
tricts, like tape-worms entozoa, with which echinococci have
many points of resemblance, and with which they have been
classed by many comparative anatomists. No evidence, however,
has been collected on this point. They are scarcely noticed by me-
dical authors in India, and seem to be very rare in that coun-
try, where other diseases of the liver are so common. They are
extremely rare among sailors. While I was physician to the
Dreadnought, I found a tumor in the liver containing many hy-
datids in a negro from the west coast of Africa, who died under
my care of purulent phlebitis, in consequence of bleeding prac-
* The only animals besides man, in which hydatid tumors have been found
to contain floating acephalocysts, are the monkey and the pig.
f The rule seems to hold in these animals, as in man, that when with hy-
datid tumors in the liver, there are hydatids in the lung, there are none in
the mesentery ; when there are tumors in the mesentery there are none in
the lung. Livois states that in ten sheep that he examined, eight had hy-
datids in the liver and in the lungs ; the remaining two, in the liver and in
the spleen; four oxen and two cows had them only in the liver and lungs.
1 The following striking instance of the prevalence of tape-worm in parti-
cular districts, was sent me by my brother, Dr. Samuel Budd, of Exeter : —
“ Some time ago two persons living in the same house, but members of
different families, came under my care for tape-worm. Soon after, two
sisters in a different family in the same hamlet, consulted me for tape-worm ;
and a short time since, another person, living in the same hamlet, but un-
connected with either of the preceding families, applied to me for the same
complaint. There could be no mistake about the matter, for all these persons
passed the worms.”
3G2
HYDATID TUMORS OF THE LIVER.
tised for inflammation of the lung ; but no other case of the kind
is known to have been admitted there. Mr. Busk, who has lived
in the hospital almost from its first establishment, tells me that
he does not recollect another instance. It is possible that the
diet of sailors, consisting in great part, of salt meat, may be
unfavourable to them.
From some researches lately published by Professor Klencke
of Brunswick, of which an extract is given in the Medico- Chirur-
gical Review, for April 1844, it would appear that diseases produced
by echinococci, cysticerci, and other kindred entozoa, may be
transmitted by inoculation from one animal to another.
When an hydatid tumor has formed in the liver, there is
reason to believe that, if near the surface, it may attain a large size
in a short time ; but in a great majority of cases, its growth is very
slow.
When the tumor grows rapidly, or when, from any cause, in-
flammation is set up within it or around it, the patient has severe
pain in the side and some degree of fever.
Under other circumstances, that is, when the tumor grows
slowly and is not the seat of inflammation, it is unattended by
pain, or gives rise to a sensation which the patient describes as one of
weight, rather than of pain ; and before it has attained such a size as
to interfere mechanically with the functions of the fiver or of adjacent
organs, it excites no constitutional disturbance, and is compatible
with a good state of general health. Not unfrequently, indeed,
the presence of a tumor of this kind in the substance of the fiver
is not suspected during fife, and is unexpectedly made known
by examination, post mortem A
As the tumor grows, it pushes up the walls of the belly, and
can in most cases be readily seen and felt. Even then, if no in-
flammation be set up, within or around it, the tumor is not pain-
* Sheep with numerous hydatid tumors in the liver and in the lungs are
often in excellent condition. In these animals, hydatid tumors have very
little tendency to excite inflammation of the tissue, or of the coverings of the
organs in which they form. When there are many tumors in the lungs the
sheep are, of course, short-breathed, hut they do not necessarily fall in con-
dition. In this respect, hydatids present a striking contrast to flukes, which
never exist in large numbers in a sheep, without greatly impoverishing its
blood.
SYMPTOMS.
363
ful or tender, and causes little other disturbance than that which
results from its hulk — a sense of fulness and weight in the region of
the liver, some difficulty in breathing from the restrained action
of the diaphragm, and now and then, but very seldom, ascites or
dropsy of the legs from pressure on the portal vein or the vena
cava.
The tumor may continue a great number of years, indeed for
the allotted term of human life, without causing other mischief,
hut the person is exposed to constant danger and is every moment
in risk of new sufferings, from the natural tendency of the tumor
to discharge its contents by ulceration of the walls of the sac.
The tumor may ulcerate through the walls of the belly, and its
contents he discharged outwardly ; or it may open into some part
of the intestinal canal, and its contents he discharged by vomiting
or by stool. In either case, the sac may close up, and the patient
recover. The same happy result may follow an opening of the
hydatid tumor into the lung. The danger from the tumor opening
in any of the ways specified is the greater, the older the tumor, or
rather, the firmer and less elastic the walls of the sac. If the tumor
be of recent date or the coats of the sac be very elastic, the sac may
close up as its contents are discharged, and the patient may re-
cover rapidly ; but if the walls of the sac he firm and unyielding,
so that its cavity cannot be closed, air or other matters will find
their way into it, and suppurative inflammation of its inner sur-
face will he set up, which may he so protracted as to exhaust the
strength of the patient.
But, instead of opening outwardly or into the intestinal canal
or into the lung, the tumor may burst into the cavity of the belly
and destroy the fife of the patient by shock, and by inflammation
of the peritoneum, in a few days or even in a few hours ; * —
or, otherwise still, the ulceration of the walls of the sac may
eat into the gall-bladder or into one of the ducts, bile may
flow into the sac and excite suppurative inflammation of its inner
surface, converting it into an abscess ; or the ulceration may eat
through the sac, and the liquid the sac contains may escape into tho
surrounding tissue and excite suppurative inflammation there.
This inflammation may by various ways he propagated back to the
sac, and, as before, the sac he converted into an abscess.
* See Diet, de Med. et Chirurg. pratiques. Art. “ Acephalocyste,” Obs,
6, 7, 8, and 9; and Medico-Chirurgical Trans, vol. xviii. pp. 124 and 126.
3G4
HYDATID TUMORS OF THE LIVER.
But there is still a chance of other mischief. A secondary
hydatid tumor may form in the lung, which may grow rapidly and
suffocate the patient ; or secondary hydatid tumors may form in
the liver, or in the mesentery. If there he many of these, or if
they grow rapidly, the nutrition of the patient invariably suffers —
he becomes thin and pallid and weak, and is gradually exhausted
by diarrhoea, or carried off more speedily by the occurrence of
pneumonia.
The diagnosis of an hydatid tumor of the liver, when it has
attained such a size as to he readily seen and felt, seldom presents
much difficulty. Our ignorance of the origin of such tumors or
of any particular circumstances in which they especially occur,
deprives us, indeed, of the aid in diagnosis which such knowledge
is calculated to give ; hut the presence of a large globular tumor
connected with the liver, that has grown slowly, without much
pain, without jaundice or ascites, and without fever or general
constitutional disturbance, — is almost evidence enough that the
tumor is hydatid. It can hardly be mistaken for an abscess,
which never forms and attains a large size, without a high degree
of fever ; or for malignant disease of the liver, which gives rise,
not to a large, globular, indolent, tumor, hut to an unevenness of
the surface of the liver from numerous small tumors projecting
above it, and which is, besides, associated with malignant disease
elsewhere or with the general tokens of the cancerous cachexy.
We are much more likely to take a distended gall-bladder,
which is likewise smooth and globular and may not he tender, for
an hydatid tumor — but great distension of the gall-bladder almost
always results from some mechanical impediment to the flow of
bile along the common duct, and is attended with deep jaundice.
But the disease most difficult to distinguish from an hydatid
tumor of the liver, is an aneurysm of the abdominal aorta form-
ing a tumor behind the liver. This, like an hydatid tumor, may
he globular, and may exist without much tenderness, without
jaundice or ascites, without much disturbance of digestion, and
without difficulty of breathing other than that which results from
the size of the tumor and the impediment which it offers to the
descent of the diaphragm. Circumstances that serve to mark the
tumor as aneurysmal, are — the sudden occurrence of the first
symptoms of the malady with a feeling, as of cramp, across the
TREATMENT.
3G5
epigastrium, not attended by vomiting or purging, and not fol-
lowed by jaundice; the existence of a distinct pulsation in tbe
tumor, and a bellows-sound beard over tbe last dorsal, or tbe
upper lumbar vertebrae ; but more than all, tbe great pain which the
patient suffers in the situation of the tumor, and in various other
parts of the body, especially tbe shoulders and the legs. An
aneurysmal tumor is generally very painful, and when situated
behind the liver and involving the solar plexus of nerves, is at-
tended not only with pain in the seat of disease, hut with sympa-
thetic pains in various parts of the body. These symptoms are
absent in cases where an hydatid sac forms a similar tumor, so
that by attention to them the two diseases may generally be dis-
tinguished.
Cases are, however, now and then met with, in which, from
some unusual circumstances, it may be difficult, or even impos-
sible, to pronounce that the tumor is hydatid. The tumor may
grow more rapidly than is usual with hydatid tumors and he at-
tended with greater pain and fever; or it may be so situated as
to compress tbe hepatic or the common duct, or the trunk of the
portal vein, or even the vena cava, and may thus cause permanent
jaundice, or ascites, or oedema of the legs. It is impossible to lay
down general rales for the detection of the real nature of the dis-
ease in such cases.
If an hydatid tumor of the liver which has been long indolent
should become painful and tender, and the patient should have
shiverings with much fever and constitutional disturbance, it may
be inferred that suppuration has been set up within the sac.
There are two ways in which an hydatid tumor of the liver may
be cured : — first by the secretion of a thick matter, like putty or
plaster, within the sac, either causing the destruction, or con-
sequent on the destruction, of the acephalocysts ; and, secondly,
by tbe tumor opening and discharging itself through the walls of
the belly, or through the lung, or into the intestinal canal-
The first mode of termination may be considered a cure of the
disease, because, although the tumor does not completely disap-
pear, it grows less, and ceases to create constitutional disturbance
or to be the source of further danger.
The second mode of termination — the opening of the tumor
and tbe discharge of its contents through the walls of the belly,
366
HYDATID TUMORS OF THE LIVER.
or through the intestinal canal, or through the lung — is often
followed hy obliteration of the sac, disappearance of the tumor,
and complete recovery ; but it is not unattended with danger.
As before remarked, hy the admission of air, or otherwise, sup-
purative inflammation may be set up within the sac, the discharge
of the natural contents of the sac may be followed at the end of
some clays by the discharge of pus, which may continue so as to
exhaust the strength of the patient. The probability of a favour-
able result from such an opening is greater the younger the patient
and the more recent the tumor — or rather, the greater the elas-
ticity of the walls of the sac. It is the elasticity of the walls of
the sac that closes the cavity as its contents escape and prevents
any subsequent mischief.
The chief danger of hydatid tumors of the liver arises from
their liability to open hy a process of ulceration into the cavity
of the peritoneum, or into the vessels or ducts of the liver itself.
This ulceration of the sac, which occurs sooner or later in most
hydatid tumors of the liver, seems to be owing to pressure from
distension of the sac. We have good evidence of this distension
in the forcible jet that sometimes issues when an hydatid tumor
is punctured. The fluid secreted from its inner surface goes on
stretching the sac and increasing the size of the tumor. From
the property of equal distribution of pressure through fluids, the
pressure on the walls of the sac from this cause must he the
same at every point of its surface, and the process of ulceration
will commence at that point which has the least power to resist
it. Hydatid tumors of the lungs and of the spleen are, from the
greater thinness and expansibility of the walls of the sac in those
organs, less liable to rupture from ulceration than similar tumors
of the liver.
The chief danger of hydatid tumors of the liver would, then,
he obviated, if by any means we could so modify the fluid se
creted from the inner surface of the sac as to destroy the acepha-
locysts, without causing suppuration; or if we could merely
arrest the growth of the tumor. It is not difficult to conceive
that there may he medicines which have power to effect this. An
agent, like iodide of potassium, for instance, that is absorbed into
the blood, and passes out of the body in almost every secretion,
may find its way into the fluid in an hydatid sac, and, although
it does uot destroy the vitality of the natural constituents of our
TREATMENT.
3G7
organs, it may destroy the feebler vitality of the parasites and
arrest the growth of the tumor.
There are, I believe, only two medicines — iodide of potassium,
and common salt — that have been supposed to have the power
of arresting the growth of hydatid tumors. Iodide of potassium
is much confided in by many physicians in this country, and has
been for some years very generally prescribed in this disease, but
I have not been able to meet with any decisive or satisfactory
evidence that it has the power of destroying the acephalocysts,
or of stopping the growth of an hydatid tumor. Mr. Hawkins,
in the paper before referred to, states that “ a case lately occurred
in St. George’s Hospital, in which the tumor was much lessened,
and ascites and other symptoms were got rid of for a time by
the use of iodine but he makes the significant remark that
“ the disease was ultimately fatal nearly a year after.” I quite
think, however, that our experience of this medicine encourages
us to further trial of it in such cases. It will be seen that evi-
dence of failure is much easier to be had than evidence of success,
because when the remedy fails, the diagnosis is after a time
made certain. With the internal use of the iodide of potassium,
may be conjoined the local inunction of the compound iodide
ointment.
The virtues of common salt in the treatment of hydatid tumors
of the liver are much relied on by some continental physicians,
who have recommended a strong solution of it to be applied as a
lotion, or in a poultice, over the tumor. It is worthy of remark
that common salt is the chief saline ingredient in the fluid of
hydatid tumors. In many instances, indeed, the fluid from an
hydatid cyst in the liver has been found to be quite devoid of
albumen, and to be little more than pure water holding common
salt in solution. Has the sac of an hydatid tumor any especial
affinity for common salt, and does the accumulation of this,
beyond a certain measure in the fluid within it, destroy the acepha-
locysts, or arrest their further multiplication or growth ?
The frequent failure of medical means to arrest the growth of
hydatid tumors of the liver has led practitioners to consider the
propriety of opening them — an operation that would naturally
be suggested by the observation that the bursting of a tumor of
this kind through the walls of the belly, or even into the intes-
368
HYDATID TUMORS OF THE LIVER.
tines or into the lung, is frequently followed by perfect, and
sometimes by speedy, recovery.
On many occasions, too, where an hydatid tumor has been
opened by the surgeon in mistake for an abscess, the patient has
speedily and completely recovered.
It is an important circumstance that in very few of these cases,
if in any, has the fluid collected again in the sac. When a serous
cyst — that is, a cyst whose inner surface has the character of a
serous membrane, and secretes a serous, or highly albuminous,
fluid — is thus emptied, the fluid almost always collects again,
and obliteration of the sac is effected only by causing adhe-
sive inflammation of its inner surface : hut when an hydatid
cyst is emptied the creatures within it die, and the fluid is no
longer reproduced.
In illustration of this, and in proof of the happy results of the
puncture of an hydatid tumor in some instances, I cannot do
better than cite two cases, published by Mr. Hawkins, in which
the operation was performed by Sir B. Brodie.
Case. — “A boy, about twelve years of age, was admitted into St. George’s
Hospital, under the care of Dr. Chambers, in August, 1822, having a tumor
of considerable size below the ribs on the right side, the ribs being raised
by the tumor, which evidently fluctuated. He had not the least disturb-
ance of the system, nor any derangement of the functions of the liver,
much less were there symptoms of abscess of that organ; the skin was
quite moveable, and free from inflammation, and slight inconvenience from
the size and pressure of the tumor, was alone complained of. After he had
been in the hospital a short time, a flat trochar was introduced by Mr.
Brodie below the ribs, in the part where fluctuation was most distinct, and
a pint and half of clear colourless water was drawn off, which did not
appear to contain any albumen, as no coagulation was produced by heat.
Pressure was made by a bandage after the operation, which appeared to
produce complete obliteration of the cyst, for the wound healed directly.
The hoy had not the least fever or other had symptom from the operation,
and left the hospital perfectly cured.” (Med. Chir. Trans., v. xviii., p. 118.)
In the second case,
“ The patient was a young lady, twenty years of age, and the tumor, which
was larger than in the former case, prevented her from taking exercise and
from sleeping except in a particular posture ; and there seemed to be some
slight inflammation, as she had some pain at the commencement of the disease,
a year or two before, which was increased before the operation, and she
suffered from a troublesome and almost incessant cough for the first two
or three weeks afterwards. Three pints of the same watery fluid were evacu-
TREATMENT.
300
ated, uncoagulated by heat, and with the smallest possible quantity of ani-
mal matter. The patient recovered, and six years afterwards, had had no
return of the complaint.” (Id., p. 119.)
In both these cases the sac most probably contained a soli-
tary acephalocyst.
If all cases which have been treated in the same way had
turned out so favourably, there would be no doubt as to the pro-
priety of performing the operation in question whenever the tumor
was ascertained to be hydatid. But, unfortunately, against the
successful cases must be set others in which the operation proved
fatal ; sometimes speedily, at other times by inducing protracted
suppuration of the inner surface of the sac.*
The probability of such a result, however small, will naturally
make practitioners extremely cautious in recommending the ope-
ration where the tumor produces no distressing symptoms.; and
perhaps few persons would be disposed to submit to an operation
at all hazardous, for the removal of a complaint which is attended
with no urgent symptoms, and with which life may be continued
in tolerable comfort for ten, or twenty, or even thirty years. life,
even to the most healthy, is so uncertain, liable to be cut short by
so many accidents, that in calculations of this kind our reason
must approve the decision to which our fears and our instincts
lead us, to purchase present security even by exposing ourselves
to a greater danger, provided it be remote.
If the tumor should be large, and should cause distressing-
symptoms, the operation can be recommended by stronger argu-
ments, and the patient will be more likely to submit to it. But
it is perhaps in these very cases, where the tumor is large and of
long standing, where the sac has lost some of the elasticity which
it originally possessed, that the operation is most likely to be un-
successful. Here, as in so many other cases, the opposite proba-
bilities must be balanced. The immediate benefit from the opera-
tion, if successful, and immunity from the various ills that result
from hydatid tumors of the liver when left to themselves, must be set
against the pain and the danger of the operation itself. At pre-
sent, we have not the means of estimating the degree of this
danger, and, consequently, have very imperfect data for forming
our judgment.
* See Diet, de Med. et de Chirurg. pratiques. Art. “ Acephalocyste.”
Obs. 13, 14, 1G, 19, 21.
D B
HYDATID TUMORS OF THE LIVER.
370
Some years ago the practice of opening the tumor was strongly
recommended by M. Recamier, who maintained that the danger of
the operation had been much exaggerated. His opinion was
strongly supported by five cases in which he had performed it
with complete success. He advised that the tumor should he
opened, not by the trochar or the knife, hut by means of caustic
potash ; — on the ground, that the caustic, before reaching the
tumor, would excite adhesive inflammation of the portion of
peritoneum in front of it. and that the lymph effused in con-
sequence would glue the sac to the walls of the belly, so that
none of the fluid within the sac would escape into the cavity of
the peritoneum,
Mr. Caesar Hawkins advises the opening of the tumor only
when it is large and causes much irritation, or when the health is
much disturbed by it ; and he recommends the trochar and canula,
in preference to caustic. He advises the opening of abscesses of
the liver in the same way, and thinks the danger that any of the
fluid will escape from the tumor into the cavity of the peritoneum
to be quite imaginary.
It would seem that the danger of such an event occurring,
must depend very much on the condition of the walls of the sac.
If these he very elastic, so as to force out the fluid and close up
the cavity when an opening is made into it, none of the fluid
will escape into the peritoneum. But if, — as in the case of many
old hydatid tumors, and in most, if not in all, large abscesses, —
the walls of the sac have not contractility adequate to close the
opening made by the trochar, a different result will ensue. When-
ever, by the act of breathing, or otherwise, the position of the
liver with respect to the walls of the belly is changed, so that the
opening in the sac does not correspond to the opening in the
-walls of the belly, any additional fluid that issues from the sac,
must enter the cavity of the peritoneum.
The danger from this cause may he greatly diminished by the
choice of a fit instrument. Sir B. Brodies suggestion of a flat
trochar is one of extreme importance, but perhaps a better in-
strument still, considering how limpid the fluid of hydatid tumors
usually is, would be a fine grooved needle, as recommended by
Dr. Prichard, of Bristol, for drawing off thoracic and abdominal
effusions.
With an instrument of this kind the risk that any of the fluid
TREATMENT.
371
will get into the cavity of the peritoneum must be extremely
slight, especially in young persons, or for hydatid tumors re-
cently formed ; and in all such cases, where purely medical means
fail, it will, I believe, eventually be found the best plan to eva-
cuate the tumor, as soon as full assurance is obtained of its na-
ture ; I say, as soon as full assurance is obtained, for it would
be a grievous, perhaps a fatal, error, to puncture a distended
gall-bladder, or a cancerous tumor, in mistake for an hydatid
sac.
b B 2
372
CHAPTER V.
ON JAUNDICE.
The chief diseases to which the liver is subject having now
been passed in review, it will be expected that some remarks
should he added on jaundice.
Jaundice is, indeed, a mere symptom, and, as we have seen,
may occur in most diseases of the liver, hut it is a symptom so
striking, and such an important element in any case in which it
may happen, that a separate consideration of it is almost requi-
site.
Jaundice — a yellow colour of the conjunctiva and the skin —
arises from the presence of the colouring matter of bile in the
blood and tissues. Yellowness of the skin, when it is well-marked,
is sufficiently distinctive of accumulation of the colouring matters
of bile in the blood, hut the skin may become slightly yellow from
other causes. In chlorotic girls, and in persons who have lost
great quantities of blood, the skin has often a pale yellow cast,
which seems not to depend on the colouring matters of bile. It
is analogous to the yellow tinge which surrounds a bruise-mark,
or an ecchymosis, and has been ascribed to some change in the
colouring matters of the blood. The sallowness produced in this
way may he distinguished from the slighter shades of jaundice
by the tint of the conjunctiva and by the state of the urine. In
persons whose skin is sallow from anemia the conjunctiva has a
bluish and pearly tint, and the urine is generally limpid, while in
real jaundice the conjunctiva is more decidedly yellow than the
skin, and the urine is always tinged with bile.
JAUNDICE.
373
Jaundice may be produced in two ways: 1st, by some impedi-
ment to the flow of bile into the duodenum, and the con-
sequent absorption of the retained bile ; and 2nd, by defective
secretion on tbe part of tlie liver, so that tbe principles of the bile
are not separated from tbe blood.
Tbe gall-bladder and the large ducts are covered by lym-
phatics, which in the natural state seem to absorb, chiefly, the
water of the bile. If bile be retained for some time in the gall-
bladder, it becomes dark coloured and concentrated, from the
absorption of part of its water. But the colouring matter is ab-
sorbed as well, though in less proportion. If the cystic duct be
completely closed, the bile previously in the gall-bladder gradually
disappears, and after a time its place is occupied by a colourless,
or only slightly yellow, mucous fluid, secreted by the coats of the
bladder. When, however, the passage of the bile through the
common duct is impeded, and the gall-bladder and ducts are in
consequence much distended with bile, the bile passes into tbe
lymphatics much more rapidly. This was ascertained by Dr.
Saunders, more than fifty years ago, by direct experiment. He
tied the hepatic duct in a dog. Two hours after, the dog was
strangled, and the absorbents of the liver were found to be “ very
much distended with a fluid of a bilious colour, and their course,
which was very conspicuous, could be traced with the greatest ease
to the thoracic duct, the contents of which seemed only moderately
bilious.” (Saunders on tbe Liver, p. 90.)
Saunders also endeavoured to prove by experiment that under
these circumstances bile is likewise absorbed by the veins. “ A
second dog was procured, and a ligature made on the hepatic duct,
as in the preceding experiment. Two hours after, blood was
taken from the jugular vein, and set to rest, in order that it might
separate into its serum and crassamentum. The liver was then
drawn down a little from the diaphragm, and blood taken from
one of the hepatic veins. Tins blood, as well as the former, was
allowed to separate into two parts ; and on immersing pieces of
white paper into the serum of each, that taken from the hepatic
veins gave the deepest tinge, the other produced only a very
slight degree of discolouration.”
Many other pathologists have also observed the colouring
matters of bile in the lymphatics coming from the liver, in cases
374
JAUNDICE.
in which the gall-ducts have been obstructed. “ Tiedemann and
Gmelin, after tying the ductus choledochus in dogs, found the
lymphatics of the liver filled with a fluid of a deep yellow colour:
the lymphatic glands which these lymphatics passed through
were yellow; and the yellow fluid taken from the thoracic duct,
contained the components of the bile.” *
These observations clearly prove the absorption of the co-
louring matters of bile in considerable quantity, when there
is an impediment to the flow of this fluid into the intestine. The
inference has been drawn from them that in such cases the jaun-
dice is produced solely by absorption of the retained bile ;
hut this inference is not warranted by the facts. Distension of
the gall- ducts must tend to keep the secreted bile in the lobules,
and in so doing, may lessen the activity of the secretion there
going on. It is only in this way that we can explain the circum-
stance noticed by Dr. Saunders, that after the hepatic duct had
been tied two hours, the serum of the blood was more deeply
tinged with bile in the hepatic vein than in the jugular vein. If
secretion by the hepatic cells had been active, the bile that was
absorbed by the veins of the gall-bladder and ducts, would probably
have been again laid hold of by the 'cells, while passing through the
capillary network of the lobules. We have seen, too, that when
the common duct has long been completely closed, all the hepatic
cells are completely broken up, and the liver is consequently in-
capable of any longer secreting bile.
These considerations render it probable that the jaundice which
follows closure of the common duct does not result merely from
absorption of the retained bile ; but also, in part, from the secre-
tion of the liver being less active, so that the principles of bile are
retained in the blood.
But in many cases of jaundice, perhaps in the greater number,
there is no impediment to the flow of bile through the ducts. In
fatal cases, it happens not unfrequeutly that the gall-bladder and
ducts are found empty, and their mucous membrane unusually
pale, — showing that no bile was secreted. The jaundice results
solely from suppressed, or deficient, secretion.
It has long been a question, whether the blood, in jaundice,
* Muller’s Physiology. Dr. Baly’s Translation, p. 276.
JAUNDICE.
375
contains perfect bile or some of its principles merely. Glisson
supposed that bile exists ready formed in the portal blood, and
is merely separated in the liver — as he expresses it, peculiari
colatorio, by a kind of filtration. It is now well known tliat urea
and some other components of the urine pass off in this way.
They exist ready formed in the blood, and are merely separated
from it by the kidneys. The colouring matters of the bile are
likewise formed in the blood, and, as far as we can judge from our
present tests, seem to pass off through the liver without change.
The addition of dilute sulphuric acid in sufficient quantity to
the serum of the blood, in jaundice, changes, after a few minutes,
its yellow colour, to the characteristic green colour of acid bile.
But it has not been satisfactorily proved that the matter, which
under the name of picromel, or biliary matter, or choleic acid,
has been considered to be the essential part of bile, exists fully
formed in the blood ; and many still hold that it is formed from its
constituents in the blood by a chemical process in the liver.
Some chemists, indeed, among them Orfila, state that they have
found hile, or at least the resinous matter of bile, in the blood, in
jaundice; but others have failed to detect it. Lecanu, whose in-
vestigations on the composition of the blood in different diseases
are among the most recent, and seem to have been conducted
with much care, states that the blood in jaundice contains the
colouring matter of bile, but that he has never been able to find
in it any of the other ingredients. This discrepancy in the results
of the analysis of jaundiced blood made by different chemists, may
be accounted for by the fact that the peculiar biliary matters are
still but imperfectly characterised, and are readily decomposed,
and enter readily into new combinations ; and, perhaps, in part,
by tbe supposition, that the condition of the blood may vary,
according as the jaundice depends on suppressed secretion of bile
merely, or on absorption of retained bile also.
The natural constituents of the blood seem at first to be little
affected by the retention, or the re-absorption of the principles of
bile. When jaundice has lasted some time, the globules of
the blood are almost always in less than the proportion of health ;
but this probably results mainly from tbe disease by which the
jaundice was produced, and from the defective nutrition that is
370
JAUNDICE.
the consequence of the absence of bile in the intestines. Andral
states that he has many times analysed the blood of persons with
jaundice; but never found the fibrin in greater proportion than
in health. From this we can only infer that in these cases, the
jaundice was not the effect of extensive inflammation ; but from
the frequent occurrence of petechias on the skin, and of hemor-
rhage from the stomach and various organs in protracted jaundice,
it would seem that in most cases of jaundice, the fibrin of the
blood is reduced after a time in still greater proportion than the
globules.
When the colouring matter of the bile is in such quantity in the
blood a3 to produce jaundice, it is eliminated in most of the secre-
tions. It passes off most abundantly in the urine, to which,
when the urine is collected in considerable quantity in a deep
vessel, and otherwise healthy, it gives a dark, almost black, colour,
with somewhat of a greenish tint — not unlike that of a strong in-
fusion of senna. The urine in a shallow white vessel, appears of
a brilliant yellow. The presence of the colouring matter of bile
is readily detected in urine by the yellow colour which it gives to
a piece of white linen dipped in the urine, or by the urine, — which
appears yellow in a shallow white vessel, or in a test tube, — be-
coming of a dark green, and afterwards purple, on the addition of
a sufficient quantity of sulphuric acid. The colouring matter of
bile may be detected in this way in the urine, even before the skin
becomes yellow, and in some cases the readiness with which it
passes off in the urine, seems to prevent the occurrence of jaundice
— the skin retaining its natural colour, while the tint of the urine
attests the presence of bile. It is astonishing, however, how
deeply the urine may be tinged with hile, and yet the jaundice
persist. This is attributable to the intense colour of acid bile,
and to the circumstance that a small quantity of it, like a small
quantity of blood, makes a great show when mixed with water.
The colouring matter of bile passes off also by the skin, and if the
patient perspire much his linen is stained yellow. This has been
repeatedly noticed ; but the most striking instance of it I have read
of, is recorded by Dr. Cheyne, of Dublin. In his account of a
case of jaundice, he says, “ The indisposition was so slight, that
the individual in question had no intention of sending for a physi-
cian, till she discovered that the bilious tinge of her skin was
JAUNDICE.
377
imparted to her linen. To satisfy my doubts she repeatedly wiped
her face with a cambric handkerchief, which thereby acquired a
saffron colour.” *
The tears and the fluid of serous cavities have likewise been
found tinged with the colouring matter of bile ; and more than
one physician has remarked it, or something like it, in the milk.
Dr. Marsh mentions, that in examining the body of a woman who
died in the Lock Hospital, Dublin, of protracted disease, with
jaundice ; “ the mamma: appeared full ; and by moderate pressure
there were obtained from them several ounces of a yellow, tena-
cious, fluid, having all the properties of pure bile.” In a case
given by Dr. Bright, of a woman who suckled her child within
three weeks of her death : “ The adipose matter wms deeply stained
with jaundice, as was the secretion which flowed from the lacti-
ferous tubes, on cutting through the mammary glands.” f
Mucus contains the colouring matter of bile much less fre-
quently than other secretions. The mucus secreted by the sto-
mach and intestines has never, I believe, been found tinged with
it, except when bile has continued to flow into the intestine ; but
mucus brought up from the lungs has occasionally been re-
marked to be yellow or green.
The different tissues in the body are tinged in jaundice, in very
different degrees. In all cases in which the jaundice depends on
closure of the common duct, the liver itself is more deeply jaun-
diced than any other organ or tissue. If the jaundice have lasted
long the liver has a deep olive colour from the retention of bile.
Where, on the contrary, the jaundice depends on suppressed
secretion, the liver is not more deeply jaundiced than many other
tissues. Instead of being of an olive colour, it has some tint com-
pounded of pale yellow and brown or red.
After the liver, the skin is perhaps the tissue that becomes the
most deeply jaundiced. The tint of the skin in jaundice varies,
in different cases, from a bright lemon colour to a dark olive, ac-
cording to the natural hue of the complexion, the quantity of fat,
and the quantity of biliary pigment retained in the skin. In
young persons, who are plump, and naturally fair, the tint of the
skin is a bright yellow, the depth of which depends on the degree
* Dublin Hospital Reports, vol. iii. p. 2(59.
f Guy’s Hospital Reports, vol. i. p. G23.
378
JAUNDICE.
of jaundice ; while in the wrinkled skin of thin old age, when the
jaundice has lasted some time, the tint is olive, or dark green.
The deep jaundice of the skin doubtless depends on the biliary
matter being separated from the blood by the secreting cells of the
skin, as it is naturally by those of the liver. The skin and the liver are
allied in their office : — both excreting superabundant fatty matter.
Many of the constitutional states that favour the secretion of the
one, favour that of the other. The skin becomes, thus, in some
measure, an index of the manner in which the functions of the
liver are performed. Horse-exercise, which clears the skin, clears
the liver ; mercury, our most effective cholagogue, is excreted in
large quantity by the skin.
The biliary pigment thus secreted by the skin in jaundice is
retained there, giving the skin a deeper stain than that of most
other tissues.
The yellow colour of the skin in jaundice remains a consider-
able time — especially in elderly persons — after the flow of bile into
the intestine has been restored, and when the urine is no longer
much tinged with bile. This stain of the skin, from the retention
of the biliary pigment, after the hepatic obstruction is removed, is
diminished in a very striking manner by warm baths. We should
be careful not to be misled by it, and thus to continue active re-
medies when they are no longer necessary. Persons with jaundice
from temporary obstruction to the gall ducts, are sometimes drug-
ged with mercury long after the function of the liver is re-esta-
blished, for a yellowness of skin, for which warm baths, and
whatever causes perspiration, are the proper remedies.
The biliary pigment seems also fixed in an especial manner in
the adipose cellular tissue, as if there were some affinity between
the colouring matter of bile and fatty substances. In some races,
indeed, the fat is naturally of an orange colour. It is so in
the cows of Guernsey ; and I have more than once remarked it in
negroes from the west coast of Africa, who were not jaundiced.
The biliary pigment is not retained in the same special manner
in other tissues. The lungs and the kidneys, though they may con-
tain as much blood, have not the green colour of the liver or skin.
The mucous membranes are the tissues that are among the
least tinged in jaundice. The tongue and the inside of the lips,
in jaundice, have not the yellow colour of the skin; and the
JAUNDICE.
379
mucous membrane of the intestines is sometimes quite white. It
lias already been remarked that mucus is less frequently jaundiced
than other secretions. The mucous membrane of the intestines
seems indeed never to eliminate the colouring matters of bile.
It sometimes happens that the cornea, or the humors of the
eye, become jaundiced, and all objects appear yellow. The notion
seems to have formerly prevailed that this is generally the case
in jaundice, but it happens, on the contrary, very rarely. The
error of supposing it of constant, or of frequent, occurrence, doubt-
less originated, as Morgagni suggested, from the yellow colour of
the conjunctiva in jaundice.
But, besides the colour of the different secretions and of the
skin, which characterizes jaundice, there are other symptoms,
which depend on the absence or the deficiency of bile in the intes-
tines, and on its presence in the blood, and which may therefore
be considered symptoms of jaundice, without reference to the par-
ticular condition of the liver on which the jaundice depends.
Thus, from want of bile in the intestines, the bowels are apt to
be confined, and the evacuations are pale, or of a drab colour,
and sometimes unusually offensive. These characters of the eva-
cuations are not, however, observed in all cases, but only where
the flow of bile into the intestine is completely stopped. Bile
enough may flow into the intestine to give to its contents their
usual characters, and yet the secretion may be inadequate to free
the blood of all the colouring matters of bile, and the person
may be jaundiced. Not unfrequently, in slight cases of jaundice,
especially where this results from suppressed secretion, the dis-
charges from the bowels present no striking deviations from
their natural state.
In almost all cases of jaundice the patient grows thin, and, as
before remarked, the blood becomes much impoverished ; the glo-
bules and the fibrin falling much below their natural standard.
The impairment of nutrition is, however, in some cases not very
marked, even after the jaundice has lasted a considerable time.
Drs. Graves and Stokes mention that in two cases of deep jaun-
dice that had fallen under their notice, after the onset of the dis-
ease, “ the derangement of the digestive organs subsided, the ap-
petite returned, the bowels became regular, although the stools
380
JAUNDICE.
did not contain a particle of bile, and nutrition continued unim-
paired, although the disease had in one case lasted for eight months,
and in the other for two years.”*
I have already mentioned the case of a man, to whom my at-
tention was called in the Dreadnought, who was pretty well nou-
rished after four years of jaundice, during which the flow of bile
into the intestine seemed to have been completely prevented.
Another symptom frequently observed in jaundice is a very
troublesome itching of the skin. This does not occur in all cases
of jaundice, and when it does occur, it sometimes disappears after
a short time. It may come and go several times in a lingering
case. The itching seems not to depend on the colouring matter
merely of bile. It does not vary with the depth of the jaundice.
Dr. Graves, indeed, has noticed that itching sometimes precedes
the jaundice, and ceases as soon as this appears. (Clinical Medi-
cine, p. 463.)
In some cases, jaundice is attended with hut little general dis-
order— and the patient, if he were not yellow, would not consider
himself ill But, generally, besides pain or tenderness in the re-
gion of the liver, and disorder of digestion, there is a sense of
languor and debility ; the person complains of being drowsy, and
the pupils are dilated. These symptoms have been ascribed to
the presence of bile in the blood, which has been supposed to
lower, in some way or other, the nervous energy.
Now and then, the drowsiness passes into delirium or coma,,
and the patient dies very speedily from disorder of the brain.
The interesting question at once occurs, — On what does this fatal
disorder of the brain depend ? It is clear that it does not depend
merely on an unusually large quantity of biliary pigment in the
blood, because it very seldom occurs in the jaundice that arises
from complete closure of the common duct, which is deeper than
any other jaundice.
It occurs, as before remarked, peculiarly, indeed almost exclu-
sively, in jaundice which results solely from suppressed secretion.
Dr. Alison has endeavoured to explain this, by supposing that
bile retained in the blood is much more hurtful than bile re-
absorbed after having been secreted.
But this supposition is inadequate to explain the fact. We
* Dublin IIosp. Reports, vol. v. p. 109-
CAUSES.
381
lmvc endeavoured to show, that where jaundice results primarily
from closure of the common duct, the lobules of the liver soon
become gorged with bile, and their secretion is rendered less active
— so that even in such cases the jaundice results in part from sup-
pressed secretion. The inadequacy of the supposition is shown
still more clearly by a case related in a former chapter, (p. 183,)
where, from long-continued closure of the common duct, the cells
of the liver were completely destroyed some time before death, so
that the secretion of bile must have been completely stopped, and
yet there was no appreciable disorder of intellect almost to the
last day of life.
The delirium and coma in these terrible cases do not depend
merely on the secretion of bile being suppressed, but on the poi-
soned state of the blood, or on the rapid disorganisation of the
liver, by which the suppression of bile is caused.
Jaundice, as already remarked, is rather a symptom of dis-
ease than the disease itself, and may arise from various causes
which it is very important that we should be acquainted with ; be-
cause a knowledge of the cause, or of the circumstances under
which the disease arose in any particular case, often gives us an
insight into its real nature, which we could scarcely obtain from
considering the symptoms merely.
The most obvious cause of jaundice, and which was therefore
the earliest assigned ; — which was, indeed, at one time assigned
almost to the exclusion of all others, — is some obstruction in the
gall-ducts, preventing the flow of bile into the intestine. This
obstruction may arise in various ways.
It may be caused by a gall-stone passing out of the gall-bladder,
and becoming impacted in the common duct. The jaundice that
occurs during the passage of gall-stones, is caused in this way.
It is generally of short duration, soon going off when the obstruct-
ing stone has passed into the intestine. But it now and then
happens that a gall-stone becomes permanently fixed in the common
duct, or leads to permanent closure of the duct by inflammation,
and of course the resulting jaundice is permanent.
A more frequent cause of jaundice from obstructed gall-ducts,
is cancerous disease of the liver, or of the pancreas. In such
cases the obstruction is permanent, and the jaundice continues till
the death of the patient.
382
JAUNDICE.
Jaundice, from closure of the ducts, now and then occurs in
that form of adhesive inflammation of the liver brought on by
spirit-drinking, which sets in with severe inflammatory symptoms,
and which leads to adhesive inflammation of the capsule of the liver,
and to the effusion of much lymph in the portal canals. In such
cases the jaundice generally goes off when the inflammatory symp-
toms subside ; hut sometimes the common duct becomes perma-
nently closed or narrowed, by the contraction of lymph effused on
its outer surface, and the jaundice is permanent.
Jaundice from obstruction of the gall-ducts may also be caused
by inflammation originating in the ducts, which, from their small
size, must he readily closed by viscid mucus, or by inflamma-
tory swelling of their lining membrane. It is probable that this
is a frequent cause of jaundice, hut at present we cannot surely
distinguish jaundice so produced from jaundice resulting from
suppressed secretion.
Jaundice occasionally arises from constipation, when it is
caused probably by the loaded intestine pressing on the common
duct, and impeding the flow of bile through it. It soon disappears
when the cause is removed.
Jaundice, brought about perhaps in the same way, occasionally
occurs during pregnancy. It goes off after child-birth, and may
sometimes be removed before by efficient purgatives.
Spasm of the gall-ducts has also been assigned as a cause of
jaundice, and was at one time advanced to explain all cases of
it in which no mechanical impediment to the flow of bile
was found after death ; just as spasm of the intestines was sup-
posed to be the cause of colic, and spasm of the bronchi the cause
of difficulty of breathing, in all cases in which no other ready ex-
planation of these symptoms could be found. Spasm of the gall-
ducts is, however, something more than a mere hypothesis. The
contractility of the common gall-duct, as well as of the efferent
ducts of other glands, has been proved by experiment. Muller
states that by irritating mechanically, or by galvanism, the ductus
choledochus of a bird just dead, he has frequently produced a
very strong contraction of it, which continued some minutes ;
after which the duct resumed its previous state. We must then
admit the muscularity of the gall-ducts, and the consequent pos-
sibility of their being contracted by spasm ; but we can hardly
suppose the spasm to be lasting enough to cause jaundice. If
8
CAUSES.
383
jaundice be produced by mere spasm of tbe gall-ducts, it must
surely be very slight and transient.
But, although a mechanical impediment to the flow of bile into
the intestine, is sometimes the origin of jaundice, it is much less
frequently so than was formerly imagined. In a large proportion,
perhaps in the greater number of cases, jaundice results primarily,
and solely, from the secretion of bile being suppressed or deficient.
The secretion of bile may be suppressed, or be rendered
inadequate, by various causes; especially by those which lead
to disorganization or atrophy of the lobular substance of the liver,
by which the bile is secreted.
Thus, in suppurative inflammation of the liver, the inflamed
portion ceases to perform its office, and when this portion is large,
the patient is in consequence jaundiced. When the suppurative
inflammation involves only a small portion of the liver, a suffi-
ciency of bile may be thrown off by the sound portions, and there
may be no jaundice.
In adhesive inflammation of the liver, brought on by spirit-
drinking, when this occurs with severe inflammatory symptoms,
there is frequently jaundice ; but, as before remarked, the jaun-
dice here seems to result from the gall- ducts being closed by the
pressure of the lymph effused in the areolar tissue about them.
This form of inflammation seems not to involve, primarily, the
lobular substance of the liver, but rather the portal veins, and the
areolar tissue in the portal canals. In the end, however, by ob-
literating branches or small twigs of the portal veins, it leads
to atrophy of the secreting substance of the liver, and in this
way also may cause jaundice. But tbe jaundice in the advanced
stages of bob-nailed or granular liver, unless the hepatic or
tbe common duct be at the same time closed or narrowed, is
always very slight, — in most cases, a sallowness, rather than de-
cided jaundice.
But jaundice occurs from other changes in the secreting sub-
stance of the liver, which are unattended by tbe effusions charac-
teristic of inflammation. It lias been remarked by Abercrombie
and by Andral, that jaundice now and then comes on in the
course of pneumonia of the lower lobe of the right lung. I have
witnessed this occurrence two or three times. The jaundice
seems to depend on a change in the secreting substance of the
384
JAUNDICE.
liver, which is different at least from ordinary inflammation.
The substance of the liver near the diaphragm is paler and softer
than it should he, and the capsule can he readily stripped off, hut
no pus or lymph is seen there.
Jaundice occurs, too, and jaundice of the most fatal kind, from a
species of softening and disorganisation of the lobular substance of
the liver, which we have still less reason to consider inflammatory.
The circumstances under which this disorganization occurs
and the other symptoms that attend it, lead to the inference that
it is produced by some poison, either introduced from without or
resulting from faulty digestion, which, without exciting inflam-
mation of the liver or leading to effusions characteristic of this state,
destroys at once the vitality of the tissues. It would seem, also,
from the instances in which jaundice has occurred in several
members of a family, or in several persons living together, in quick
succession, some of whom have died rapidly, with disorganiza-
tion of the liver, while others have completely recovered — that
the disease may stop short of disorganization of the liver, per-
haps even of any appreciable change of its structure. We have
seen, too, that jaundice from arrest of secretion may occur from
various contaminations of the blood — as by pus, the poison of
serpents, the poison of severe remittent fevers — which perhaps do
not at once lead to appreciable change of structure. Jaundice,
probably from suppressed secretion, occasionally results also from
the taking of opium.
The jaundice, that sometimes results from powerful depressing
emotions, or from mental shock, probably depends, also, on
arrest of secretion. In the majority of cases of this kind, the
jaundice is attended by no alarming symptoms, and soon passes
off ; but now and then, it proves rapidly fatal by disorder of the
functions of the brain.
Jaundice occurs in various other circumstances, astheresult either
of arrest of secretion, or of inflammation and consequent closure
of the gall-ducts. I have met with several instances in which it
occurred during a course of mercury, given for syphilis ; and ap-
parently in effect of the medicine. In none of these cases has it
been attended with alarming symptoms.
Dr. Graves has remarked that jaundice followed by urticaria
now and then occurs during the course of arthritis. Tie says,
“ A person labouring under inflammation of the joints gets an
CAUSES.
385
attack of hepatitis, accompanied by jaundice, and this is followed
by urticaria. I have observed this sequence of disease in eight
or nine cases. The first was in a gentleman residing in Lower
Mount Street, whom I attended with Dr. Cheyne. This gentle-
man, in consequence of exposure to cold, was attacked with
arthritic inflammation and fever. After he had been ten days ill
he became suddenly jaundiced, and in a day or two afterwards
a copious eruption of urticaria appeared over his body and limbs.
Exactly the same train of phenomena, and in a similar order of
succession, were observed in a man treated in the Meath Hos-
pital, in 1832. A short time before this, I had been attending
a medical friend in Baggot Street, who had been affected in the
same way ; and I mentioned to the class, as soon as I perceived
the man was jaundiced, that he would most probably get urticaria.
I made a similar prediction in a case which occurred recently
in our wards, and it was verified by the event. Now, this is
not a mere fortuitous occurrence ; the various symptoms must
he connected in the relation of cause and effect.” Clinical Medi-
cine, p. 564.
It would seem, from Dr. Graves’s silence on this point, that the
jaundice in these cases was not attended by alarming disorder of
the brain. I have never remarked the train of phenomena here
pointed out by Dr. Graves ; hut in more than one instance I have
observed jaundice to exist in conjunction with an extensive scaly
eruption, which appeared nearly at the same time, and which was
apparently dependent on the same cause.
The only other variety of jaundice that I can call to mind, is
the jaundice that is now and then observed in newly-born children.
It occurs a few days afterbirth, and soon disappears. It has been
advanced, that this is not real jaundice, hut that the yellow
colour of the skin results from extravasation or retention of blood
in the skin, and that it is analogous to the yellow stain that follows
a severe bruise. The deep red colour of the skin, which is fre-
quent in the new-born infant, gradually fades, and passes through
different shades of yellow to the colour proper to flesh. M.
Bouisson states, however, that M. Chevreul has found the colour-
ing matters of bile in the blood of infants in whom this jaundiced
colour of the skin existed. (Bouisson, p. 147.)
Since, then, jaundice may arise from such various causes, and
c c
386
JAUNDICE.
be a symptom in diseases so different, it is clear that we cannot
foretel its issue in any given case, or have well-grounded confidence
in our treatment, unless we can pass from the jaundice to the par-
ticular disease of the liver on which it depends, or to the parti -
lar cause by which it is produced.
In some cases we have little difficulty in doing this. We can
generally, for instance, interpret the slight shade of jaundice that
occurs in the granular or hob-nailed liver. We are sufficiently
informed of the nature of the disease by the previous habits of the
patient, and by the symptoms of impeded circulation through
the liver, that are almost always present in these cases, when there is
jaundice. Frequently, too, we can interpret the jaundice that
occurs during the passage of a gall-stone, or in the course of
cancer of the liver, by the presence of other symptoms indicative
of those diseases.
When, again, there has been, for a considerable time, deep
jaundice, without any bilious tinge in the matters discharged from
the bowels, and without alarming head-symptoms, we may be sure
that the common or the hepatic duct is closed in some way or
other, and that the jaundice results from mechanical impediment
to the flow of bile into the intestine.
But in many cases, with our present knowledge, it seems impos-
sible to trace the jaundice to its source, and especially to tell
whether it depends on inflammation of the gall-ducts, or on sup-
pressed secretion of bile. Our knowledge of the causes of these
several diseases at present helps us but little to distinguish them.
In a former chapter I have given the details of several cases,
collected from different authors, in which jaundice from sup-
pressed secretion proved fatal, and in which the lobular substance
of the liver was found to be completely disorganized, or very much
softened. I placed these cases together with the view of exhibit-
ing the characters of this obscure disease, which is far more im-
portant than the fatal cases merely, which are few, would lead us to
suppose. It is clear from the instances in which jaundice occurred
in several members of a family in succession, that jaundice of this
kind does not always prove fatal ; and that occasionally it is
attended by no alarming symptoms. It is possible, therefore,
that a considerable proportion of the cases of jaundice that we
TREATMENT.
387
meet with in practice, and especially in young persons, may be of
this kind.
It appeal's from the cases before related, that in mild forms
of the disease, the patient’s illness begins with general disorder ;
with languor or listlessness, vague pains in the belly, and some-
times with vomiting ; but without much fever. In a day or two,
jaundice comes on, hut the flow of bile into the duodenum is not
completely stopped — the matters brought up by vomiting, or
passed by stool, are still bilious. The jaundice may continue
* some time with no more alarming symptoms, and may then go
off gradually, and the patient gradually recover. But, now and
then, after it has continued in this state from a few days to
several weeks, head symptoms come on, and the patient soon dies
comatose.
In more acute forms of the disease, the illness begins with
symptoms more like those of remittent fever : — with fever, vomit-
ing, and thirst, and furred tongue, and headache, and restlessness.
In a day or two, jaundice comes on, soon followed by drowsiness,
or active delirium, which speedily passes into coma.
Two circumstances that may serve to distinguish this variety
of jaundice, are, 1st, that the liver is not enlarged, — generally,
indeed, in the cases that prove fatal, it is found to be much
smaller than natural ; and 2nd, that the flow of bile into the
duodenum is seldom completely stopped ; the discharges from
the stomach and bowels are still tinged with bile.
The treatment of jaundice must of course be guided chiefly by
reference to the condition of the liver, on which the jaundice is
supposed to depend.
Where there is reason to believe, from tenderness in the region
of the liver, or fulness in the right hypochondrium, and other
circumstances, that the jaundice results from inflammation in the
substance of the liver, or in the excreting ducts, — leeches or
cupping, fomentations, saline purgatives, and diet, are the reme-
dies that should first be employed. In adhesive inflammation of
the liver, and in inflammation of the gall-ducts, local bleeding
always produces great relief. When the activity of the inflam-
mation has been somewhat subdued by these means, recourse
may be had to mercury, in order to promote the absorption of
effused lymph ; or to correct the acrid quality of the bile which
c c 2
388
JAUNDICE.
seems frequently to cause, and keep up, inflammation of the
ducts.
In other cases where jaundice occurs without previous organic
disease, and, there is reason to believe, from suppressed secretion
merely; — where the patient feels languid and oppressed, and has
occasional vomiting, and the pupils are dilated, while there is no
fulness, and not much tenderness, in the region of the liver, and
the flow of bile into the intestine is not quite stopped, — the pro-
priety of bleeding, or of giving mercury, is very doubtful. From
what we yet know of the pathology of such cases, these measures
seem much more likely to do harm, than to do good. It is safer
to he content with diaphoretics and saline purgatives, than to
use, as it were, in the dark and at hazard, our more powerful
remedies.
If the patient should become very drowsy, and especially if
sluggishness of the pupil and other symptoms should betoken
approaching coma, we should give strong purgatives so as to
cause copious discharges, and at the same time endeavour to
rouse the brain by blisters to the scalp, and other excitants.
Cases have been before related, in which recovery took place
under these measures, even after the patient had fallen into a
state of almost complete coma. The tendency of free purging
to remove the coma, or lessen the stupor, when this exists, leave
httle doubt that it tends also to prevent it, and suggests the
propriety of the systematic and active use of saline purgatives in
this variety of jaundice.
Mild saline purgatives, as the Seidlitz, Pullna, or Cheltenham
waters, continued for some time, seem often of great service
during the decline of jaundice, and when the time for more active
measures is past.
In the jaundice that results from closure of the common duct,
it is clear that mercury and all lowering remedies must do harm.
All to be done, is, — to regulate the diet ; to prevent the accumula-
tion of noxious matters in the bowels by an aloetic pill, or other
warm purgative ; to keep up the action of the skin by an occa-
sional warm bath ; and to take care to do nothing likely to dis-
order the action of the kidney through which the bile finds its
way out of the system.
More active interference would be still more injurious, when the
closure of the duct is caused by malignant disease.
APPENDIX.
The liver-fluke — Its efl’ects on sheep and other graminivorous animals. Flukes
found in the gall-ducts, in the duodenum, and in branches of the portal vein,
in man.
The gall-bladder and ducts of most of our graminivorous ani-
ipals, and especially of the sheep, are frequently infested by two kinds
of parasites — the Distoma Hepaticum and the Distoma Lanceo-
latuvi — which are often found together, and are commonly con-
founded under the term, liver-JIulce. They are the cause of the
distemper in sheep, which is known as the rot, and which is so
justly dreaded by the farmer.
The distoma hepaticum is, in shape,
very like a small sole or flounder, and,
when full grown is, in the sheep, from
three quarters of an inch to an inch
and a half in length, and from one-
third to half an inch wide, at the widest
part. It has two suckers, whence the
name. Distoma. One of these is at
the extremity of the head, (a) fig. 16,
and is a little turned downwards ; the
other, ( b ), which is the larger of the
two, is on the under surface of the
body, at the base of the neck. The
first leads to the alimentary canal, and
is pierced by the mouth; the hinder
one is imperforate, a mere organ of
adhesion.*
* See Owen’s Lectures on the Comparative Anatomy of the Invertebrate
Animals, from which the account of the anatomy of the liver-fluke tn the
text is chiefly taken.
Fig. 18.
a
Distoma Hepaticum, from a sheep.
Natural size.
390
THE LIVER-FLUKE.
Between the suckers, is a small depression, (c) in which are the two
genital pores.
The alimentary canal is for a very short distance from the first sucker
a single tube, and then divides into two, which diverge a little to embrace
the genital pores and the hinder sucker, and then run parallel to each other
along the middle of the body to near the tail, where their ends are closed.
These parallel tubes send off many branched tubes from their outer sides,
which extend nearly to the margins of the body. The ends of all these
tubes are closed or blind.
The organs of both sexes are in the same individual. The male organs
are situated between the alimentary tubes. Convoluted seminal tubes,
which may be recognised by their opaque white colour, occupy a great
extent of the middle part of the body, and terminate by two trunks in a
common canal, which ends at the base of the penis. The penis when flaccid,
is spiral, and not unfrequently may be seen projecting from the anterior
genital pore. The ovaria occupy the whole margin of the body for a fine
Fig. 19.
Distoma lanceolatum, magnified,
a , b, the suckers j c, d, d, the ali-
mentary canal ; e, e, male organs ;
f, f, ovaria ; g, g, the ramified
uterine tube, h, outline of D. lan-
ceolatum, of natural size. ( Oiven ,)
in breadth. They consist of minute
branched tubes in which the ova are
developed. The oviducts terminate
in a single large canal, which opens
by a distinct pore immediately behind
the male bursa, after making many
convolutions between this and the hinder
sucker.
The body is soft, almost of gelatinous
consistence, and semitransparent; and
of a whitish colour, variegated near the
margins by the yellow ova, and within
by the double ramified alimentary canal,
which is greenish or brown from con-
taining the colouring matter of bile.
The Distoma lanceolatum, which was
at one time regarded as the young of
the Distoma hepaticum, is much smaller,
being commonly about a quarter of an
inch in length, very seldom half an inch.
It also differs in shape from the Dis-
toma hepaticum. The outline of the
body, instead of being rounded at each
end, as in the latter, has each end lan-
cet-shaped ; the end terminated by the
head being much the narrower or more
pointed of the two. The sucking cups
are placed as in D. hepaticum, but are
larger.
EFFECTS IN SHEEP.
391
There are also differences in the internal structure of the two varie-
ties.
In the D. lanceolatum, the alimentary, canal does not ramify as in D.
hepaticum. It is a single tube to the genital pore, which is here midway
between the suckers, and then divides into two, which go along near the
margins of the body, without sending off any branches, almost to the tail,
where their ends are closed. The male organs are contained in the anterior
part of the space between the alimentary tubes. The ovaria are situated
at the margins of the middle third of the body, outside the alimentary tubes.
The oviducts run transversely and terminate in a common uterine tube,
which is very long and tortuous, occupying all the hinder part of the space
between the two alimentary tubes.
In slieep, these parasites are often found in great numbers.
Many hundreds may sometimes be counted in a single liver.
They produce remarkable changes in the gall-ducts they inhabit,
and through them in the adjacent parts of the liver. The gall-
ducts infested by them become dilated, and their coats much
thickened. In cutting across the liver, after the rot has lasted
for some time, we see many branches of the hepatic ducts, of the
size of a large quill, with thick coats having much the look of
soaked leather. These ducts are stuffed with flukes, and often
with a dirty greenish matter, the excrement and ova of the flukes,
enveloped in mucus. The ova are egg-shaped bodies, all nearly
of the same size — ^-i-g of an inch long, and about -g-g-g of an inch
broad. Under the microscope, they are yellow by transmitted
light, have a distinct single outline, and appear solid and filled
with very fine granular matter.
At first, only the larger branches of the hepatic duct are changed
in the way described. The smaller branches, which are not yet
reached by the flukes, are healthy. It often happens, too, that
while some of the larger ducts are so changed, others contain no
flukes, and are quite healthy. After a time, the infested gall-
ducts are still more changed. Those near the under surface of
the liver often form white tubes, tlie largest the size of the
thumb, or larger, which project above the surface, and in some
parts are visible, without dissection, quite to the edge of tho
liver. On the convex surface of the liver, the dilated tubes,
being deeper seated, are not visible except in a spot, here and
there, near the edge. The coats of these white prominent gall-
392
THE LIVER-FLUKE.
clucts are much thickened, and have the look and almost the
toughness of cartilage. On tracing them from trunk to branch,
we sometimes find one closed, or blind, at the further end, from
obliteration of the smaller branches which went to form it. These
blind tubes are filled with mucus and the remains of flukes, which
die when deprived of the bile on which they subsist. It now
and then happens, too, that a portion of a dilated duct becomes
separated from the rest, so as to form a cyst, which is filled with
mucus.
Those parts of the liver in which the ducts are much dilated
are more or less atrophied, from pressure and from obliteration
of some of the small ducts, and are pale and shrunken, as com-
pared with other parts of the same liver in which the ducts are
less diseased. Occasionally, a thin false membrane is found on
the convex surface of the most diseased portion of the liver, and
uniting this by threads to the contiguous organs.
Later still, the inner surface of the ducts becomes incrusted
with chalky matter (carbonate of lime) which in the end transforms
them into bony tubes. Now and then we find a small cyst filled
with chalky matter and completely isolated from the tubes ; the
remains perhaps of what was at one time a mucous cyst.
The effects which these parasites have on the health of the sheep
are also very striking. At first, the sheep has a remarkable apti-
tude to grow fat, and, if the accumulation of fat only he regarded,
may he prepared for the butcher perhaps weeks sooner than a
sheep perfectly sound. This circumstance has even been turned
to profit. Sheep nearly ready for slaughter, have been purposely
placed in a pasture that gives the rot that they might fatten more
quickly. But, unfortunately, while they grow fat, their muscles
waste, and, from the first, they are weak and languid. They soon
become anemic and now and then slightly sallow. They are re-
cognised by butchers as having the rot, chiefly by an unusual
whiteness of the eye, which does not show the red vessels seen in
the eye of a healthy sheep. The caruncle, too, at the corner of
the eye, is pale, and often slightly yellow ; and the skin, when the
wool is parted, does not exhibit the ruddy hue of health, but is
pale and sometimes sallow. There is also a tendency to oedema,
which is first conspicuous in dropsical swelliug of the legs just
EFFECTS IN SHEEP.
393
above the bocks ; but before this appears, the skin is looser than
in a healthy sheep, — it is more readily stripped off by the butcher. *
As the disease goes on, the fat disappears, and the animal loses
flesh rapidly, and grows extremely feeble. The appetite fails and
the bowels are irregular ; sometimes costive, at other times much
purged. The oedema increases, the skin in consequence becomes
loose and flabby, and gives out a peculiar crackling sound when
pressed, and the belly also gets dropsical. The wool now comes
off at the slightest pull, the skin often becomes spotted with yellow
or black, (probably from ecchymosis,) and the animal dies a mere
skeleton, — generally from two to six months from the commence-
ment of the disease. The rot, however, is not inevitably fatal.
Sheep frequently recover, if early removed to a healthy pasture.
It will at once be seen that the chief symptoms of the disease
and its fatal issue, depend, not so much on the changes of structure
in the liver, striking as these are, as on an unhealthy state of the
blood. The disease may prove fatal, when part only of the liver
is involved, and when more than enough is left for all the pur-
poses of secretion. The sallowness of the caruncula lachrymalis,
and of the skin, occasionally noticed, is always slight, never
amounting to jaundice, and depends probably more on anemia than
on bile. The blood becomes impoverished in this disease just as
it does from granular degeneration of the kidney, in man. The
paleness of the conjunctiva and of the skin, that may be noticed
even at an early period, show diminution in the proportion of
globules in the blood. M. Anclral has ascertained that when the
disease has gone on to dropsy, the proportion of albumen is like-
wise much diminished, and he adduces this circumstance as
* These symptoms from being so obvious, were early noticed. They are
pointed out very distinctly in the famous “ Booke of Husbandrye,” published
more than three centuries ago, (the Booke of Husbandrye, by Sir Anthony
Fitzherbert, 1532,) when from the general want of draining, the rot must have
been more destructive in this country than now. “ Take both your handes,
and turn up the lid of his eye, and if it be ruddye and have red stringes in
the white of the eye, then he is sound, and if the eye be white like talowe and
the stringes dark-coloured, then he is rotten.”
“ And also take the shepe upon the wol on the side, and if the skin be of
a ruddye color and dry, then is he sound, and if it be pale-colored and watery
then he is rotten.” (Library of Useful Knowledge. Treatise on the Sheep,
p. 446.)
394
THE LIVER-FLUKE.
strongly in favour of the opinion he has advanced, that the
dropsy from granular kidney, and in this disease, as well, is caused
immediately by loss of the albumen of the blood. In sheep in-
fested with flukes, the kidneys are pale like the other tissues, hut
not otherwise altered in structure ; and the urine does not contain
albumen. The yellow and black spots on the skin often noticed
in the advanced stage of the disease, if they result from haemor-
rhage, as they probably do, would lead us to infer that at this date,
the proportion of fibrin in the blood is also diminished. The blood
becomes at length so drained of all its organic constituents — glo-
bules, albumen, fibrin — that it is no longer fit to nourish the
body and maintain life. The death of the animal is hastened
by diarrhoea, which recurs frequently, especially towards the
close of the malady, occasioned probably by irritating matters
passing into the intestines from the gall-ducts.
No one, I believe, has inquired, how flukes in the liver work
this change in the blood. It cannot be by merely consuming the
bile, unless this is much more necessary for digestion in sheep
than in man. Do they not cause a drain of serum from the tissues on
which they fasten, and in the texture of wliich they produce
such striking changes ?
I have described thus fully the characters of this disease in
sheep, not only on account of the intrinsic interest which it
must have for the pathologist, but also on account of its great
national importance — which alone is a sufficient reason why
it should be investigated by medical men, who are the persons
best qualified by previous education for such a task, and who are
many of them placed in circumstances very favourable for it.
Some notion of the importance of this disease may be formed from
the statement made by a high authority on the diseases of cattle,
that more than a million sheep and lambs die of it annually in
this country.* In some seasons, this number, vast as it is,
is much exceeded. In the winter of 1830-31, it was far more
than doubled ; and in some of the midland, eastern, and southern
countries, where the pestilence was most rife, the existing race of
sheep was almost entirely swept off.
Besides the sheep that actually die of the disease, vast numbers
of those which are slaughtered are infected with it, and their flesh,
* Library of Useful knowledge. Treatise on the Sheep, p. 445.
7
CAUSES OF THE ROT IN SHEEP.
395
we may suppose, is less wholesome ancl nutritious in conse-
quence. In the spring of the present year (1844) a consi-
derable proportion of the sheep that were brought to the London
market, were infested with flukes. I had no difficulty in getting
from the butchers any number of diseased livers to examine.
But the disease is not confined to England. It prevails in
other countries of Europe, as far north as Norway, and in the
most southern provinces of Spain. It occasionally prevails like-
wise in North America ; and in Van Dieman’s Land and Australia,
it has at times been quite as destructive as here.
Flukes have been found nowhere hut in the liver, or duodenum,
of graminivorous animals. They usually inhabit the gall-ducts,
where, as we have seen, they produce countless numbers of ova, or
spawn, most of which must pass into the intestine, and he dropped
by the sheep on the pastures. It is stated that from November
to April, minute oval particles, which are doubtless these same
ova, may occasionally he seen in swarms in the droppings of
the infected sheep. They probably, under favourable circum-
stances, retain their vitality for a long period. The rot is most
probably propagated by the sheep swallowing the ova or embryos
thus dropped on the pastures ; and by the young flukes passing
instinctively from the duodenum into the gall-bladder and ducts.
(Owen.)
But although the disease is so far propagated by infection,
other conditions, of soil and season, are necessary for its spread.
The rot is almost confined to marshy or wet grounds, and is
unusually destructive after a wet summer or autumn, or during
a wet winter. It does not spread in dry seasons, or during hard
frosts, and never shows itself on dry sandy soils, except after long
rains. Autumn and winter are the seasons in which it prevails
most. Meadows may often be safely pastured in spring, which
are most destructive in autumn or winter. Another circumstance
of practical importance, and which also seems to be well established,
is that, season and soil alike, the disease spreads much more in
lands that are over-pastured. This has been attributed, in part,
to the ground being then broken by numberless foot-marks, which
are so many cups in which the water collects.
It is generally believed, too, that at night, or while the dew is
on the grass, the infection spreads much more than by day ; and
396
THE LIVER-FLUKE.
it has been in consequence laid down as a precept, that when a pas-
ture is suspected to be rotting, the sheep should be folded early
in the evening, and not be released till the dew is partly evapo-
rated.
In an infected pasture, a whole flock of sheep may be tainted
in a very short time. Of this some very striking instances have
been recorded, in a manner so circumstantial, that consideiing
their antecedent probability, there seems no reason to doubt their
reality. The two following will perhaps suffice.
“ A farmer in the neighbourhood of Wragby, in Lincolnshire, took twenty
sheep to the fair, leaving six behind in the pasture on which they had been
summered. The score sent to the fair, not being sold, were driven hack, and
put into the same field in which the six had been left. In the course of the
winter every one of them died of the rot : but the six that had been left be-
hind all lived and did well. There could be no mistake with respect to this
fact, as the sheep sent to the fair had a different mark from that ' of the six
that were left at home. The loss of these twenty sheep can only he accounted
for on the supposition that they had travelled over some common, or other
rotting ground, and there became infected.”
The second instance is still more conclusive.
“ A sheep, belonging to a lot of twenty, being lamed in consequence of a
broken leg in getting out of Burgh fair, in Lincolnshire, the nineteen were
suffered to range on a common at the end of the town until a cart could be
procured to carry the maimed sheep home. The nineteen all died rotten,
while the sheep with the lame leg continued perfectly free from the disease.*
It follows at once from these observations that the most effectual
way to prevent the rot, is to make the pastures dry by thorough
draining. In order that the disease may spread, it seems neces-
sary that the soil should be wet or marshy, or at least that there
should be stagnant water on it. It is perhaps enough that there
be stagnant ditches about a field, though the field itself be dry.
Sheep, more than any other of our domestic animals, require a dry
soil.
Oxen are likewise infested with flukes, but in much less
degree. They are not rotted by them, like sheep, and will thrive
on pastures destructive to sheep. I have learnt from a farmer
* Lib. of Useful Knowledge. Sheep, p. 153. Quoted from Parkinson on
Live Stock, vol. i. p. 421.
PREVENTION OF THE ROT IN SHEEP.
397
in Devonshire that in rich meadows on the banks of the Taw,
where the beautiful nortli-Devon cattle are bred and thrive, sheep
can never he kept for any length of time. They almost invariably die
of the rot in less than twelve months from their being brought there.
The meadows, though drained enough to produce rich grass, are
low, and divided by ditches in which the water is almost stagnant.
Various other precepts for the prevention of the rot may be
drawn from the observations that have been mentioned, but
which it would be out of place to dwell on here. They are most
of them obvious enough, and are well expressed in works on
this and similar subjects,* and are, besides, pretty generally
known and acted upon by prudent farmers. The great point to
inculcate is the importance of thorough draining. More ills of
man and beast than we yet suspect are probably owing to the
want of it ; and it is fortunate for the future generations of both
in this country, that farmers are now becoming sensible of the
remarkable effect of thorough draining in increasing the fertility
of land, and are thus led to undertake it by the only motive that
is generally efficient — the expectation of a profitable return.
When sheep are once infected, there is little hope for them
unless they be speedily removed to a healthy pasture. When
this is done, many will still die, for they carry with them the
parasites, which, once in their appointed abode, will perhaps
continue to find there all that they require for their growth and
propagation ; but many of the sheep will recover.
The medicine, whose efficacy is best established in this dis-
ease, is common salt, of which as much should be given as
the sheep will eat. It has been long known that sheep
hardly ever become rotten in salt marshes, except in years when
the disease is extraordinarily rife ; and that they usually recover
when placed in such pastures if they be only slightly tainted.
Of late years, many agriculturists have given strong testimony in
favour of the efficacy of salt sprinkled on the animal’s food, or
given to it forcibly, not only in preventing the rot, but in curing
it, when not far advanced. (Op. Cit., p. 450.)
* I would especially refer the reader who is desirous of more information
on this subject, to the very elaborate and interesting treatise on the sheep, to
which I have already referred.
393
THE LIVER-FLUKE IN MAN.
It would seem that the salt not only prevents the further mul-
tiplication of the flukes, but that it destroys those that already
exist in the liver of the animal.
Condiments of various kinds seem to have similar efficacy.
Gentian and ginger are those most in repute. They have
been recommended to he given in powder, in conjunction with
salt. It is probable that various aromatic herbs have similar
virtue, and that good might result from planting in lands that
give the rot, some such herb of a kind that sheep will eat and
that will grow there. In high grounds, where sheep feed on
dry aromatic herbs, the rot never occurs.
It has been already remarked that other graminivorous animals
are liable to he infested with flukes. Hares and rabbits that feed
on the same pastures, are rotted like sheep. They become thin
and pot-bellied, and lose their flax, and at length die much wasted
Oxen also are infested by them, hut much less than sheep, and
they do not suffer in health in the same degree. Flukes have also
been found in the liver of the deer, and of the pig, — and, in a few
instances, in man ; hut in no animal exclusively carnivorous.
In man, liver-flukes are so rare, and when present are generally
so few in number, that they must he considered a curiosity, rather
than a cause of disease.
Bucholz found a considerable number of flukes in the gall-
bladder of a prisoner who died of putrid fever. Rudolphi, who
got possession of some of them, states that they were precisely like
the Distoma lanceolatum of the sheep. Rudolphi had many other
specimens, also of Distoma lanceolatum, that had been passed by
a girl after having taken a dose of Ghabert's empyreumatic oil.
He states that he could not find an authentic instance of a speci-
men of Distoma hepaticum having been fouud in the human
liver.
Brera found some flukes in the gall-ducts of a man who died of
scurvy complicated with dropsy, which were larger than those
found by Bucholz, and which were considered to be of the variety
D. hepaticum.
A few years ago, a single fluke was discovered by my colleague,
Mr. Partridge, in the gall-bladder of a person who died in the
Middlesex Hospital. Mr. Partridge was present at the examina-
tion of the body, and was struck with the appearance of the gall-
bladder, which, instead of being stained by bile, as is usual, was
THE LIVER-FLUKE IN MAN.
399
perfectly white. He took the gall-bladder away, to make of it a
preparation to show the natural structure, and, on laying it open,
discovered the fluke. He presented the fluke to Professor Owen,
who considered itto differ in no respect from the Distoma hepaticum
of the sheep. The gall-bladder and cystic duct, which were
perfectly healthy, are preserved in the museum of King’s Col-
lege.
In the winter of 1843, fourteen flukes were found by Mr. Busk
in the duodenum of a Lascar, who died in the Dreadnought.
There were none in the gall-bladder or ducts. These flukes were
much thicker and larger than those of the sheep, being from an
inch and a half to near three inches in length. They resembled
the Distoma hepaticum in shape, hut were like the Distoma lanceo-
latum in structure ; the double alimentary canal, as in the latter
variety, being not branched, and the entire space between it towards
the latter part of the body being occupied by a branched uterine
tube. Two of these flukes, which were given me by Mr. Busk,
are in the museum of King’s College, (Prep. 346) and from one
them, which is injected with size and vermilion, the annexed wood-
cut (fig. 20,) was made.
Fig. 20.
Fluke, from the duodenum of a
man, (natural size,) injected, a, ligature
round the neck ; b, alimentary tube.
Some flukes were also found
by Brera in the human duo-
denum ; where they doubtless
subsist, as in the liver, on the
bile.
Rudolphi mentions, merely to
deny the assertion, that some
authors, to whom he gives no
reference, have stated that flukes
occasionally inhabit also the
branches of the portal vein. An
observation, however, made
some years ago by M. Duval, a
physician at Rennes, confirms
these statements. In the be-
ginning of April, 1830, M.
Duval, while engaged on the
veins in a course of anatomy,
had, to illustrate his lectures,
400
THE LIVER-FLUKE IN MAN.
the body of n man, about forty-nine years of age, who died in a
hospital at Rennes. While demonstrating the portal vein at
lecture, M. Duval discovered that there was a foreign body in its
trunk, and on carefully laying the vein open, he found that this
was a Distoma hepaticum, of large dimensions, in the midst of a
little fluid blood. Subsequently, in tracing the hepatic divisions
of the vein, he found four or five others, of the same kind.
There were none in the mesenteric branches that go to form the
trunk of the portal vein. The branches of the vein that con-
tained the flukes presented no erosion nor any marks of inflam-
mation, and had quite their natural appearance. The liver else-
where was sound, and, excepting the flukes, nothing particular
was remarked in the body. The man was brought into the medical
wards of the hospital on the 24th of March, and died on the 28th.
No particulars of his case are given. The flukes are preserved in
the museum at Rennes. In 1842, when they had been twelve
years in spirit, they were found to he from eleven to fourteen lines
in length, and from four to five lines wide.
From M. Duval’s account, which is very detailed, there seems
to he little doubt that these parasites were really specimens of
Distoma hepaticum M. Duval states that he found them to ac-
cord with plates of the D. hepaticum, in the ‘ Encyclopedic and
that he subsequently showed them to M. Dujardin, a high autho-
rity, he says, in such matters, who pronounced them to be really
of this species.*
In this instance, the flukes obtained immediately from the portal
blood the means of subsistence which they generally draw from
the bile. It is remarkable, considering the great changes that are
produced by flukes in the texture of the gall-ducts in sheep, that
there were here no marks of disease in the coats of the veins
which the flukes infested. Is it (as the symptoms of the disease
which they occasion in sheep render probable) that flukes require
some of the principles of the blood for their support, as well as
•bile and that in the gall- ducts they obtain these by causing a
■drain: of serum from their coats ? It is remarkable, too, that
■ thiij r \ excrement and spawn should not have set up disease in the
'.fiflbgtance of the liver, and thus have led to appreciable changes
of texture. But, perhaps, the greatest puzzle is — how did the
flukes get into the vein ? We are led to infer that they grew
* Gazette Medicate de Paris, 3 Decembre, 1S42.
THE LIVER-FLUKE IN MAN.
401
up there, from there having been no erosion of the coats of the
veins, nor any other marks of disease in them. Besides, there
were no flukes in the gall-ducts, nor any signs of flukes having-
been there at some former time. But, supposing that the flukes
grew in the vein, how did the eggs, which are so much larger
than blood-globules, get there ?
The supposition that the Distomata withdraw the albumen of
the blood, accounts for their producing less effect on larger
cattle than on sheep, hares, and rabbits. A loss of albumen
that would exhaust these small animals, would have little effect
on an ox.
THE END.
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AN OUTLINE OF THE ANATOMY AND PHYSIOLOGY OF THE SKIN.
8vo. cloth, 10s. 6 d.
Extract from Preface.
“ Such is a brief sketch of the scheme, which I propose to designate a Natural
System of Classification of Diseases of the Skin, and I trust that its clearness and
simplicity will be the means of rendering a branch of medical science, which has hitherto
with much reason been regarded as obscure and confused, intelligible and precise. . . . The
basis of the Natural System of classification rests upon Anatomy and Physiology, and
herein lies its strength, its easy application, and its truth. The Dennis and its dependen-
cies, its glands and its follicles, are the undoubted seat of all the changes which charac-
terize cutaneous pathology.”
“ We have now reached the conclusion of the volume, and our perusal has been both agreeable and
instructive. The book is not written for a day, but for an age; the style is good and precise, the lan-
guage well selected, and the information which it contains, genuine and copious. We think it
adapted to cast a new light on the pathology and treatment of diseases of the sldn, and to form an
admirable guide to the medical practitioner, to whom and to the student we warmly recommend it.”
— Dr. Johnson's Review.
“ Mr. Wilson’s volume is an excellent digest of the actual amount of knowledge of cutaneous dis-
eases ; it includes almost every fact or opinion of importance connected with the anatomy and pa-
thology of the skin.” — British and Foreign Medical Review.
By the same Author.
THE ANATOMIST’S VADE-MECUM;
& Jjjigtcnt of Suntan Anatomy.
WITH 167 ILLUSTRATIONS ON WOOD.
Second Edition. Foolscap 8vo. cloth, 12s. 6(7.
“We noticed with high praise, on its first publication, this singularly beautiful and excellent
work. This new edition calls for our repetition of our encomiums, and with interest, inasmuch
as all the old merits are enhanced by cognate novelties both of text and illustration.” — British and
Foreign Medical Review.
DR. WILLIAMS, F.R.S.
PROFESSOR OF THE PRACTICE OF MEDICINE, UNIVERSITY COLLEGE, LONDON.
PRINCIPLES OF MEDICINE;
COMPREHENDING GENERAL PATHOLOGY AND THERAPEUTICS.
Demy 8vo. cloth, 12s.
By the same Author.
THE PATHOLOGY AND DIAGNOSIS OF DISEASES OF THE CHEST;
Illustrated chiefly by a Rational Exposition of their Physical Signs.
Fourth Edition, with much important new matter.
Plates. 8 vo. cloth, 10s. 6(7.
“ The fact that a fourth edition is called for is a very good argument in favour of any book. But
this was not necessary in the case of Ur. Williams ; it was well known to the profession as one of the
best manuals of diseases of the chest we possess.” — Dublin Medical Journal.
MR. CHURCHILL'S PUBLICATIONS.
Z*
—
F.
H. RAMSBOTHAM, M.D.
Fe-
CONSULTING PHYSICIAN IN OBSTETRIC CASES TO, AND LECTURER ON OBSTETRIC MEDICINE
AT, THE LONDON HOSPITAL; PHYSICIAN TO TIIE ROYAL MATERNITY CHARITY, ETC.
MH ©WIFI EOT IFILTOTMTIEPo
THE PRINCIPLES AND PRACTICE OP
OBSTETRIC MEDICINE AND SURGERY.
In one handsome thick 8vo. volume. Illustrated with 84 Plates, engraved on Steel,
and 20 on Wood, from Original Drawings. Cloth, 22s.
“ We regard this work, between accurate descriptions and useful illustrations, as by far the most
able work on the principles and practice of midwifery that has appeared for a long time. Dr. Rams-
botham has contrived to infuse a larger proportion of common sense and plain unpretending prac-
tical knowledge into his work, than is commonly found in works on this subject ; and as such we
have great pleasure in recommending it to the attention of obstetrical practitioners.” — Edinburgh
Medical and Surgical Journal.
“ This is one of the most beautiful works which have lately issued from the medical press ; and is
alike creditable to the talents of the author and the enterprise of the publisher. It is a good and
thoroughly practical treatise ; the different subjects are laid down in a clear and perspicuous form,
and whatever is of importance, is illustrated by first-rate engravings. A remarkable feature of this
work, which ought to be mentioned, is its extraordinary cheapness.” — Edinburgh Journal of
Medical Science.
“ Dr. Ramsbotham has treated the subject in a manner worthy of the reputation he possesses, and
has succeeded in forming a book of reference for practitioners, and a solid and easy guide for
students. Looking at the contents of the volume, and its remarkably low price, we have no hesita-
tion in saying that it has no parallel in the history of publishing.” — Provincial Medical and Surgical
Journal.
“ It is the book of midwifery for students ; clear, but not too minute in its details, and sound in
its practical instructions.” — Dublin Journal of Medical Science.
“ Our chief object now is to state our decided opinion that this work is by far the best that has
appeared in this country. The value of the work, too, is strongly enhanced by the numerous and
beautiful drawings, which are in the first style of excellence.” — Medical Gazette.
“ We most earnestly recommend this work to the student who wishes to acquire knowledge, and
to the practitioner who wishes to refresh his memory, as a most faithful picture of practical mid-
wifery.”— Dr. Johnson1 s Review.
JOHN RAMSBOTHAM, M.D.
LATE LECTURER ON MIDWIFERY AT THE LONDON HOSPITAL; CONSULTING PHYSICIAN TO
THE ROYAL MATERNITY CHARITY.
PRACTICAL OBSERVATIONS ON MIDWIFERY,
WITH A SELECTION OF CASES.
Second Edition. 8vo. cloth, 12s.
Extract from, Preface.
“ In offering to the medical public a second edition of my Practical Observations on
Midwifery, I propose to condense the contents of the two parts of the first edition into
one moderate-sized volume. And I indulge the hope, that the work will contain such
practical remarks upon the various cases which occasionally occur, derived from per-
sonal observation and bed-side experience, as may tend to confirm the wavering mind of
the young practitioner in his judgment and subsequent practice. . . . Dr. Dcwes states, in his
advertisement to the American edition, ‘ that he was so much pleased with Dr. Rams-
botham’s work on Midwifery, that he thought lie would be doing an acceptable office to the
medical community in America, should he cause it to be re-published. He believes he does
not say too much when he declares it to be, in his opinion, one of the best practical works
extant.1 ”
“ This is an excellent work, and well deserves a place in the first rank of practical treatises on the
obstetric art. ... It is characterised throughout by the eloquence of simplicity and plain good sense,
and it has the inestimable merit of keeping perpetually to the point Not only as a companion
to other works, but for its intrinsic merits, it ought to have a place in every public and private medical
library.” — Medico-Chirurgical Review.
-©*-
JO-
Wl R. CHURCHILL'S PUBLICATIONS.
*06-
-SO-
ROBERT LISTON, F.R.S.
SURGEON TO THE NORTH LONDON HOSPITAL.
PRACTICAL
OR OPERATIVE
Third Edition. 8vo. cloth, 22s.
SU RG E RY.
Extract from Preface.
“ A third edition having been called for, the letter-press lias been revised and corrected
with care; extensive additions have been made ; and a great many new wood-engravings
added. These improvements, it is hoped, may render the work more useful to surgical
pupils, and better entitled to the patronage of the profession at large.”
WILLIAM PROUT, M.D. F.R.S.
ON THE NATURE AND TREATMENT OF
STOMACH AND RENAL DISEASES;
BEING AN INQUIRY INTO THE
CONNEXION OF DIABETES, CALCULUS, AND OTHER AFFECTIONS
OF THE KIDNEY AND BLADDER WITH INDIGESTION.
Fourth Edition. With Six Engravings. 8vo. cloth, 20s.
Extract from Preface.
“ Since the third edition was published, Professor Liebig’s treatises have made their
appearance, and attracted no little notice. Some of the views advanced by this distin-
guished chemist, are the same I have long advocated. Others of his views are directly
opposed to mine, and seem to me to be neither susceptible of proof, nor even probable.”
“ tVe acknowledge and have pride in bearing testimony to the high qualifications of our country-
man in the branch of pathological inquiry based upon chemical facts ; we recognize the comprehen-
sive sagacity of his speculations, and respect the patient zeal with which he has toiled to erect upon
these a stable system ; the important connexion between a large number of disordered states of the
urinary secretion and disordered states of the processes of digestion and assimilation. . . .We have
only to repeat our conviction that no student or practitioner can be regarded as even tolerably
acquainted with the subject who has notread and re-read them.” — British and Foreign Medical
Review.
ALFRED S. TAYLOR,
LECTURER ON MEDICAL JURISPRUDENCE AND CHEMISTRY AT GUY’S HOSPITAL.
A MANUAL OF MEDICAL JURISPRUDENCE AND TOXICOLOGY.
Foolscap 8 vo. cloth, 12s. Cxi.
Contents. — poisoning — wounds — infanticide — drowning — hanging — strangu-
lation SUFFOCATION LIGHTNING COLD STARVATION RAPE PREGNANCY
DELIVERY — BIRTH INHERITANCE LEGITIMACY INSANITY, &C. &C.
The Student’s Books for Examination.
By Dr. Steggall.
1. A MANUAL FOR THE USE OF STUDENTS PREPARING
FOR EXAMINATION AT APOTHECARIES’ HALL. Ninth Edition. 12mo.
cloth, 8s. 6(1.
2. A MANUAL FOR THE COLLEGE OF SURGEONS ; intended
for the Use of Candidates for Examination and Practitioners. One thick volume. 12mo.
cloth, 12s. 6 d.
3. GREGORY’S CONSPECTUS MEDICINiE THEORETICS. The
First Part, containing the Original Text, with an Ordo Verhorum, and Literal Translation.
12mo. cloth, 10s.
4. THE FIRST FOUR ROOKS OF CELSUS ; containing the Text,
Ordo Verhorum, and Translation. 12mo. cloth, 8s.
*,* The above two Works comprise the entire Latin Classics required for Examination at
Apothecaries’ Hall.
f
4
MR. CHURCHILL'S PUBLICATIONS.
1
©*-
U
MR. LAWRENCE, F.R.S.
SURGEON TO ST. BARTHOLOMEW’S HOSPITAL.
30-
A TREATISE ON RUPTURES.
The Fifth Edition, considerably enlarged. 8vo. cloth, 16s.
“ The peculiar advantage of the treatise of Mr. Lawrence is, that he explains his views on the
anatomy of hernia and the different varieties of the disease in a manner which renders his book
peculiarly useful to the student. It must be superfluous to express our opinion of its value to the
surgical practitioner. As a treatise on hernia, it stands in the first rank.” — Edinburgh Medical
and Surgical Journal.
DR. C. REMIGIUS FRESENIUS,
CHEMICAL ASSISTANT IN THE GIESSEN LABORATORY.
ELEMENTARY INSTRUCTION IN CHEMICAL ANALYSIS,
AS PRACTISED IN THE LABORATORY OF GIESSEN.
WITH A PREFACE BY PROFESSOR LIEBIG.
Edited by LLOYD BULLOCK, late Student at Giessen.
Demy 8vo. cloth, 9s.
The original work has had a most extensive sale and reputation in Germany. The
English edition has been prepared with the co-operation of the A uthor : it contains much
neiv matter, and the latest improvements in processes, and will therefore be much in advance
of the German edition.
“Dr. Fresenius conducts the course of elementary instruction in mineral analysis, in
the laboratory of the University of Giessen. During the two last sessions he has followed
the method described in his work This method I can confidently recommend from my
own personal experience for its simplicity, usefulness, and the facility with which it may
be apprehended.
“ I consider Dr. Fresenius’ work extremely useful for adoption in institutions where
practical chemistry is taught; but it is especially adapted to the use of Pharmaceutical
Chemists.
“Further, a number of experiments and discoveries have been recently made in our
laboratory, which have enabled Dr. Fresenius to give many new and simplified methods
of separating substances, which will render his work welcome.
JUSTUS LIEBIG.”
“ A review of this book has been written by Professor Liebig, and a more competent critic of its
contents could not be found. We may add, that in every respect the present publication is well
timed and acceptable in England. The course of study laid down in Dr. Fresenius’ work is excel-
lent. Chemistry is rapidly extending its attractions, not only in our own profession in this country,
but amongst manufacturers, agriculturists, and all classes of educated men.” — Lancet.
MR. NASMYTH, M.R.C.S. F.L.S. F.G.S.
RESEARCHES ON THE
DEVELOPMENT, STRUCTURE, AND DISEASES OF THE TEETH.
8 vo. cloth, plates, 10s. 6d.
“ Such interesting and important discoveries have lately been made on the structure of the teeth,
and so important have these organs become as guides to the anatomist in the classification of the
different members of the animal kingdom, that a new work on the subject was imperatively called for,
and the demand could not have been more efficiently responded to than it is by Mr. Nasmyth in
the work before us.” — Lancet.
11 Here we terminate our notice of this interesting and important volume, strongly recommending
it to the attention of all who arc interested in the scientific investigation connected with our profes-
sion.”— Medical Gazette.
A
By the same Author.
THREE MEMOIRS,
WITH ILLUSTRATIONS, on the DEVELOPMENT and STRUCTURE of
THE TEETH AND EPITHELIUM.
Second Edition. 8vo. cloth, 6s.
■30
MR. CHURCHILLS PUBLICATIONS.
-*9
-pe-
GOLDING BIRD, M.D. F.L.S. F.G.S.
ASSISTANT-PHYSICIAN TO GUY’S HOSPITAL.
ELEMENTS OF NATURAL PHILOSOPHY;
BEING AN EXPERIMENTAL INTRODUCTION TO
THE STUDY OF THE PHYSICAL SCIENCES.
ILLUSTRATED WITH UPWARDS OF THREE HUNDRED WOODCUTS.
Second Edition. Foolscap 8vo. cloth, 12s. Gd.
“ By the appearance of Dr. Bird’s work, the student has now all that he can desire, in one neat,
concise, and well- digested volume. The elements of natural philosophy are explained in very simple
language, and illustrated by numerous woodcuts.” — Medical Gazette.
“ This work teaches us the elements of the entire circle of natural philosophy in the clearest and most
perspicuous manner. Light, magnetism, dynamics, meteorology, electricity, &c., are set before us
in such simple forms, and so forcible a way, that we cannot help understanding their laws, their
operation, and the remarkable phenomena by which they are accompanied or signified. As a volume
of useful and beautiful instruction for the young, and as a work of general value to both sexes, we
cordially recommend it.” — Literary Gazette.
JAMES STEWART, M.D.
BILLARD'S TREATISE ON THE DISEASES OF INFANTS.
Translated from tlie Third French Edition, with Notes.
8 vo. cloth, 14s.
“ This translation of Dr. Billard’s work will supply a want felt to exist in our medical literature.
The author has enjoyed opportunities of pursuing pathological investigations to an almost unlimited
extent ; and, as the result, he has presented to the world a book remarkable for the variety and im-
portance of the facts it contains. Of the manner in which Dr. Stewart has executed his task, we can
speak in the highest terms.” — Dr. Johnson's Review.
DR. HUNTER LANE, F.L.S., F.S.S.A.
A COMPENDIUM OF MATERIA MEDICA AND PHARMACY;
ADAPTED TO THE LONDON PHARMACOPOEIA,
EMBODYING ALL THE NEW FRENCH, AMERICAN, AND INDIAN MEDICINES ;
AND ALSO COMPRISING A SUMMARY OF PRACTICAL TOXICOLOGY.
One neat pocket volume. Cloth, 5s.
“ Dr. Lane’s volume is on the same general plan as Dr. Thompson’s long known Conspectus ; hut
it is much fuller in its details, more especially in the chemical department. It seems carefully com-
piled, is well suited for its purpose, and cannot fail to be useful.” — British and Foreign Medical
Review.
DR. RYAN,
MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS.
THE UNIVERSAL PHARMACOPCEIA;
OR,
A PRACTICAL FORMULARY OF HOSPITALS, BOTH BRITISH AND FOREIGN.
Third Edition, considerably enlarged. 3’2mo. cloth, 5s. 6 Id.
Extract from Preface.
“ This work is a conspectus of the best prescriptions of the most celebrated physicians
and surgeons throughout the civilized world. It includes every medicine described in the
Pharmacopoeias, with the doses and uses, the rules for prescribing, the actions of medi-
cines on the economy, the various modes of administering them, and the principles on
which they are compounded.”
“ A vast mass of information in this little work.” — Dr . Johnson's Review.
-}0'»
— —
MR. CHURCHILLS PUBLICATIONS.
—
DR. II E N N E N, F.R.S.
INSPECTOR OF MILITARY HOSPITALS.
-IfrQ ■
PRINCIPLES OF MILITARY SURGERY ;
COMPRISING OBSERVATIONS ON THE ARRANGEMENT, POLICE, AND
PRACTICE OF HOSPITALS;
AND ON THE HISTORY, TREATMENT, AND ANOMALIES OF VARIOLA AND SYPHILIS.
ILLUSTRATED WITH CASES AND DISSECTIONS.
Third Edition. With Life of the Author, by his Son, Dr. JOHN IIENNEN.
8 vo. hoards, 16s.
DR. LEE, F.R.S.
LECTURER ON MIDWIFERY AT ST. GEORGE’S HOSPITAL, ETC.
CLINICAL Ml DWI FERY.
WITH THE HISTORIES OF FOUR HUNDRED CASES OF DIFFICULT
LABOUR. Foolscap 8vo. cloth, 4s. 6d.
Eairact from Preface.
“ The following Reports comprise the most important practical details of all the cases
of difficult parturition which have come under my observation during the last fifteen years,
and of which I have preserved written histories. They have now been collected and
arranged for publication, in the hope that they may he found to illustrate, confirm, or
correct the rules laid down by systematic writers for the treatment of difficult labours, and
supply that course of clinical instruction in midwifery, the want of which has been so
often experienced by practitioners at the commencement of their career.”
“ The cases included in these reports are of the first importance, and, digested into a synopsis,
must prove more instructive to the juvenile practitioner than a score of systematic works.”— Lancet.
“ Dr. Lee’s work will be consulted by every accoucheur who practises his art with the zeal which it
merits.” — Medical Gazette.
G. J. GUTHRIE, F.R.S.
SURGEON TO THE WESTMINSTER HOSPITAL.
ON INJURIES OF THE HEAD AFFECTING THE BRAIN.
Quarto, boards, 6s.
“ An interesting volume. The practical surgeon will find it of great value, and reference wall often
be made to its facts ; it forms a valuable addition to our existing surgical literature.” — Dr. Johnson's
Review.
“ The great practical importance of those affections which constitute Mr. Guthrie’s Treatise. A
commentary on such a theme, written by a surgeon of experience and reputation, cannot fail to
attract the attention of the profession.” — British atid Foreign Medical Review.
By the same Author.
THE ANATOMY OF THE BLADDER AND OF THE URETHRA,
AND TnE
TREATMENT OF THE OBSTRUCTIONS TO WHICH THESE
PASSAGES ARE LIABLE.
Third Edition. 8vo. cloth, 5s.
fMR. CHURCHILLS PUBLICATIONS.
-H3* —
S. ELLIOTT HOSKINS, M.D.
PROFESSOR SCHARLING
ON THE
CHEMICAL DISCRIMINATION OF VESICAL CALCULI.
Translated, with an Appendix containing Practical Directions for the Recognition of
Calculi. With Plates of Fifty Calculi, accurately coloured. 12mo. cloth, 7s. Gd.
Extract from Preface.
“ In the course of the investigations I have long been engaged in, on the subject of
solvents for urinary calculi, my attention was attracted by a notice of Dr. Scharling’s
essay, in the ‘ British and Foreign Medical Review.’ Finding, on reference to the
original work, that its value was not over-rated, I was induced to condense and arrange it,
as a text-book for my own use ; regretting, nevertheless, that its utility should be so nar-
rowly circumscribed : without the plates, however, it would have been useless to have
thought of publishing. Circumstances subsequently led to a correspondence with the
Author, who, with the utmost liberality, placed the original woodcuts at my disposal.
With this additional inducement, I did not hesitate to prepare a translation for the public,
under the hope, that it might prove to others, as practical a guide, in the discrimination
of calculi, as it had been to me.”
“ The volume of Professor Scharling gives, in the fullest and minutest manner, the information
requisite for the chemical discrimination of vesical calculi, and conveys the directions for analysis so
clearly, and with so much arrangement, that the hard-working practitioner (who is not, and cannot
he a perfect chemical analyst) may, by its aid, ascertain with precision, the composition of calculi.
The value of Professor Scharling’s book is much increased by its numerous coloured engravings of
vesical calculi, and by its description of their physical character and aspect.” — Provincial Medical
Journal.
JOHN E. ERICIISEN, M.R.C.S.
FELLOW OF THE ROYAL MEDICO-CUIRURGICAL SOCIETY, ETC. ETC.
A PRACTICAL TREATISE
ON DISEASES OF THE SCALP.
Illustrated with Six Plates. 8vo. cloth, 10s. Gd.
Extract from Preface.
“ The treatment recommended is such as I have had frequent occasion to adopt, or to
have seen put in practice by others, and it has been my endeavour to lay down the indi-
cations to be fulfilled for its proper accomplishment, in as concise and clear a manner as
possible ; and I trust that I have shown that these affections, which have been for ages
looked upon as the peculiar province of the empiric, are as amenable as any others to a
rational practice. The plates, which have been taken from nature, have been executed
by that able Artist, Mr. Perry.”
“ We would earnestly recommend its perusal to all who desire to treat those diseases upon scien-
tific rather than empirical principles.” — British and Foreign Medical Review.
“ It is with great confidence, that we recommend this treatise to the perusal of the student and
practitioner, as a most valuable contribution to a branch of practical medicine which has hitherto not
been studied with the care and attention that its importance demands.” — Medical Gazette.
DR. MILLINGEN,
LATE RESIDENT PI1YSICIAN OF TIIE MIDDLESEX PAUPER LUNATIC ASYLUM
AT HANWELL.
ON THE TREATMENT AND MANAGEMENT OF THE INSANE:
WITI1 CONSIDERATIONS ON PUBLIC AND PRIVATE LUNATIC ASYLUMS,
POINTING OUT THE ERRORS IN THE PRESENT SYSTEM.
18mo. cloth, 4s. Gd.
“ Dr. Millingcn, in one small pocket volume, has compressed more real solid matter than could
be gleaned out of any dozen of octavos, on the same subject. We recommend this vade-mecum as
the best thing of the kind wc ever perused.” — Dr. Johnson’s Review.
%
-*e-
MR. CHURCHILL'S PUBLICATIONS.
-©*-
3-©-
MR. TYRRELL,
LATE SENIOR SURGEON TO THE ROYAL LONDON OPHTHALMIC HOSPITAL.
A PRACTIGAL WORK ON THE DISEASES OF THE EYE,
AND THEIR TREATMENT, MEDICALLY, TOPICALLY,
AND BY OPERATION.
With coloured Plates. 2 vols. 8vo. II. 16s.
“ Tliis work is written in a perspicuous style, and abounds in practical information ; we add our
earnest recommendation to our readers, to procure and read through the two volumes, assuring them
that they will be richly repaid for their trouble. A series of plates, illustrative of the various diseases,
are given. ’ ’ — Dublin Journal of Medical Science.
DR. S II A P T E R,
PHYSICIAN TO THE EXETER DISPENSARY, ETC.
THE CLIMATE OF THE SOUTH OF DEVON,
AND ITS INFLUENCE UPON HEALTH.
ILLUSTRATED WITH A MAP, GEOLOGICALLY COLOURED.
WITH SHORT ACCOUNTS OP
EXETER, TORQUAY, TEIGNMOUTH, DAWLISH, EXMOUTH, SIDMOUTH, &c.
Post 8vo. cloth, 7s. 6d.
“ Independently of the important information contained in Dr. Shapter’s valuable and interesting
work, it may safely be studied as a model for those who are desirous of pursuing a similar line
of inquiry, and who wish to see the medical topography of a district treated with that singlenesss of
purpose, and philosophical candour, which should characterise the writings of every member of a
liberal profession.” — British and Foreign Medical Review .
LANGSTON PARKER,
SURGEON TO THE QUEEN’S HOSPITAL, BIRMINGHAM.
THE MODERN
TREATMENT OF SYPHILITIC DISEASES,
BOTH PRIMARY AND SECONDARY;
Comprehending an Account of improved Modes of Practice adopted in the British and
Foreign Hospitals, with numerous Formulas for the Administration of many New Remedies.
12mo. cloth, 5s.
“ An excellent little work ; it gives a clear and sufficiently full account of the opinions and practice
of MM. Iticord, Desruelles, Cullerier, Wallace, & c. Such a digest cannot fail to be highly useful and
valuable to the practitioner.” — Dublin Medical Press.
“ This little work is a useful compendium of the practice of the French surgeons. The book is ju-
dicious and well-timed, and will save many practitioners from the erroneous dullness of routine.” —
Medical Gazette.
EDWARD SHAW, M.R.C.S.
ASSISTANT-APOTHECARY TO ST. BARTHOLOMEW’S HOSPITAL.
THE MEDICAL REMEMBRANCER;
OR,
PRACTICAL POCKET GUIDE:
CONCISELY POINTING OUT THE TREATMENT TO BE ADOPTED IN THE FIRST MOMENTS
OF DANGER FROM POISONING, DROWNING, APOPLEXY, BURNS, AND OTHER ACCIDENTS.
TO WHICH ARE ADDED VARIOUS USEFUL TABLES AND MEMORANDA.
32mo. cloth, 2s. 6d.
*#* This pocket volume will he found a safe practical guide in all cases of sudden
emergency, presenting at a glance the most appropriate remedy.
-Sri 3-e-
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MR. CHURCHILL'S PUBLICATIONS.
JO-
SIR ASTLEY COOPER, BART. F.R.S.
A TREATISE ON
DISLOCATIONS AND FRACTURES OF THE JOINTS.
A NEW EDITION, MUCH ENLARGED.
Edited by BRANSBY B. COOPER, F.R.S.
With 126 Engravings on Wood, by Bagg. Octavo, cloth, 20s.
— S-£-
Extract from Preface.
“ The demand for this work having required that it should be again committed to the
press, some prefatory observations may be expected from me, in fulfilling the very grate-
ful task of Editor, which was assigned to me some time prior to the lamented decease of
Sik Astley Cooper 1 may be allowed to express the gratification I have experienced
from the sentiments expressed in the mass of correspondence, as well as from the addi-
tional cases which have been contributed from various sources since the last edition; as
they all tend to form so many various, yet concurrent testimonies to the soundness of
the principles which it is the object of this Treatise to inculcate; and much new matter
has been added, which was derived from Sir Astley Cooper himself. . . . The reader will
find the delineations copied from the quarto edition to be even more graphic and perspicu-
ous than the originals; while the illustrations, now for the first time introduced into the
work, are equally correct, clear, and expressive. The advantages of such engravings being
placed in immediate connexion with the portion of the text which they are intended to
elucidate, will not pass unnoticed by those who have felt the inconvenience of having to
search at the end of the volume for each plate to which the reference occurs in the text.”
“ Although new matter and new illustrations have been added, the price has been reduced from
two guineas to twenty shillings. After the flat of the profession, it would be absurd in us to eulogize
Sir Astley Cooper’s work on Fractures and Dislocations. It is a national one, and will probably sub-
sist as long as English surgery.” — Medico-Chirurgical Review.
“ In this work we find the last, the most matured views of its venerable author, who, with unex-
ampled zeal, continued to almost the last moment of his life, to accumulate materials for perfecting
his works. Every practical surgeon must add the present volume to his library. Its commodious
and portable form — no mean consideration — the graphic, the almost speaking force of the unequalled
illustrations, the copious addition of valuable and instructive cases, and the great improvement in
clearness and precision which has been gained by the judicious arrangement of the materials, all
combine to render the present edition indispensable.” — British and Foreign Medical Review.
By the same Author.
ON THE STRUCTURE AND DISEASES OF THE TESTIS.
ILLUSTRATED WITH TWENTY-FOUR HIGHLY- FINISHED COLOURED PLATES.
The Second Edition. Royal 4to.
Reduced from £3. 3s. to £ 1. 10s., or plain Plates, £1.
J. Churchill having purchased of Mr. Bransby Cooper this splendid work, constituting
a monument to Sir Astley Cooper’s memory, has fixed the above low price with a view to
its speedy sale ; he thinks it best to state, (having received letters of enquiry) that the
colouring of the plates, paper and type, will be found superior to the first edition.
“ The rcpublication of this splendid volume supplies a want that has been very severely felt from
the exhaustion of the first edition of it The extraordinary merits of this treatise have been so
long and so universally acknowledged, that it would be a work of supererogation to represent them
in our pages. The practical surgeon who is not master of its contents, cannot be fully aware of the
imperfection of his own knowledge on the subject of diseases of the testicle.” — British and Foreign
Medical Review.
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0 ALLNATT, (Dr.) TIC-DOULOUREUX ; or, Neuralgia Facialis, and other ^
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BY A PRACTICAL CHEMIST. THE CYCLOPAEDIA OF THREE
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